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ORTHOPEDIC  SURGERY 

FOR 

PRACTITIONERS 


The  Stretch  by  Rodin,  Usually  Called  "The  Age  of  Bronze.' 
(New  York  Metropolitan  Museum  of  Art.) 


ORTHOPEDIC   SURGERY 


FOR 


PRACTITIONERS 


BY 

HENRY   LING   TAYLOR,   M.D. 

PROFESSOR  OF   ORTHOPEDIC   SURGERY   AND   ATTENDING   ORTHOPEDIC  SURGEON, 

NEW    YORK    POST-GRADUATE    MEDICAL    SCHOOL    AND    HOSPITAL; 

ASSISTANT   SURGEON,    HOSPITAL    FOR   THE   RUPTURED 

AND  CRIPPLED,    NEW  YORK 


ASSISTED  BY 


CHARLES   OGILVY,   M.D. 

ADJUNCT     PROFESSOR     OF     ORTHOPEDIC     SUR- 
GERY, NEW   YORK   POST-GRADUATE   MEDICAL 
SCHOOL  AND  HOSPITAL  ;  ATTENDING  SUR- 
GEON, NEW  YORK  CITY  CHILDREN'S 
HOSPITAL 


FRED  H.   ALBEE,   M.D. 

INSTRUCTOR    IN    ORTHOPEDIC    SURGERY,    NEW 
YORK      POST-GRADUATE     MEDICAL     SCHOOL 
AND    HOSPITAL  ;     ASSISTANT    AND    SKIA- 
GRAPHER,  HOSPITAL    FOR  THE   RUP- 
TURED AND  CRIPPLED,  NEW  YORK 


WITH  TWO  HUNDRED  AND  FIFTY-FOUR  ILLUSTRATIONS 


NEW    YORK    AND    LONDON 

D.    APPLETON    AND     COMPANY 

1909 


Copyright,  1909,  by 
D.  APPLETON  AND  COMPANY 


PRINTED  AT  THE  APPLETON  PRESS, 
NEW  YORK,  U.   S.   A. 


TO 

CHARLES    FAYETTE    TAYLOR 
PIONEER 


"  I  look  on  that  man  as  happy,  who,  when 
there  is  a  question  of  success,  looks  into  his 
work  for  a  reply." — Emerson. 

"I  will  not  follow  where  the  path  may 
lead,  but  I  will  go  where  there  is  no  path, 
and  I  will  leave  a  trail." — Strode. 


PREFACE 


This  book  aims  to  give  an  outline  of  the  essential 
facts  in  regard  to  deformities  and  crippling  affections 
for  daily  use  in  general  practice. 

When  one  considers  the  large  number  of  congenital, 
postural,  traumatic,  paralytic,  rachitic,  "  rheumatoid," 
tuberculous,  and  other  deforming  affections  in  children 
and  adults,  it  will  be  conceded  that  they  comprise  no 
inconsiderable  part  of  the  material  which  is  presented 
to  the  practicing  physician  in  the  ordinary  course  of  his 
work.  It  is  he,  oftener  than  the  specialist,  who  has  the 
privilege  of  detecting  crippling  affections  in  their  incipi- 
ency,  when  the  application  of  comparatively  simple  meth- 
ods of  treatment  may  save  many  from  deformity  or 
death. 

A  special  effort  has  been  made  to  present  such  meth- 
ods as  are  at  the  command  of  any  intelligent  practitioner, 
and  to  eliminate  irrelevant  and  useless  matter. 

The  work  is  divided  into  general,  special,  and  tech- 
nical parts,  as  it  is  believed  that  this  arrangement  econ- 
omizes space,  emphasizes  the  importance  of  underlying 
causes,  and  is  more  convenient  for  reference.  In  the 
general  part  the  underlying  principles  are  discussed,  and 
there  are  brief  descriptions  of  the  more  important  crip- 
pling affections.     In  the  special  part  the  principal  de- 


viii  PREFACE 

formities  and  crippling  affections  of  each  part  of  the 
body  are  taken  up  in  the  toiDographical  order  given  in 
the  table  of  contents;  special  attention  has  been  paid  to 
diagnosis,  prevention,  jorognosis,  and  treatment.  The 
theory  and  practice  of  splinting,  in  its  broader  sense,  the 
mechanical  control  of  motion  and  pressure  for  therapeu- 
tic purposes,  are  given  in  the  third,  or  technical,  part. 
When  information  is  desired  in  connection  with  some 
sjDecial  case,  it  is  suggested  that  the  appropriate  section 
of  the  special  part  be  read  first,  after  which  correspond- 
ing sections  in  the  general  and  technical  parts  should  be 
consulted. 

It  is  not  overstatement  to  say  that  as  much  pains  has 
been  taken  with  the  illustrations  as  with  the  text.  With 
few  exceptions,  the  subjects  were  selected,  posed,  and 
photographed  by  the  author  especially  for  this  volume. 
The  skiagrams  were  taken  by  Dr.  Albee,  either  at  the 
Hospital  for  the  Euptured  and  Crippled  or  privately,  the 
latter  with  Dr.  Wisner  B.  Townsend's  unusually  com- 
plete installation. 

The  present  work,  containing  the  gist  of  twenty-five 
years  of  private  and  hospital  exj^erience  in  special  prac- 
tice, is  constructed  on  foundations  gained  in  close  asso- 
ciation with  the  late  C.  Fayette  Taylor,  than  whom  there 
never  was  a  sounder  or  more  inspiring  teacher.  The 
writer  is  also  under  special  obligations  to  his  friends 
Dr.  Virgil  P.  Gibney,  Dr.  Wisner  R.  Townsend,  Dr.  Eoyal 
Whitman,  and  to  the  other  members  of  the  staff  of  the 
Hospital  for  the  Euptured  and  Crippled,  and  also  to  his 
colleagues  at  the  Post-Graduate  Hospital,  for  kind  coop- 
eration and  valuable  information  and  material. 


PREFACE  ix 

There  is  scarcely  a  member  of  the  American  Ortho- 
pedic Association,  native  or  foreign,  to  whom  he  does 
not  owe  a  definite  debt;  particularly,  however,  to  the 
late  Dr.  A.  M.  Phelps,  to  Mr.  Robert  Jones,  and  to  the 
Boston  orthopedic  circle. 

While  it  has  not  been  thought  practicable  to  insert 
detailed  references  to  authorities,  the  books  and  mono- 
graphs that  have  proved  most  helpful  to  the  writer  are 
listed  at  the  end,  with  the  hope  that  they  may  also  prove 
useful  to  those  who  wish  to  pursue  special  topics  further. 

Modern  orthopedic  surgery  has  no  prejudices  for  or 
against  mechanical,  gymnastic,  or  operative  procedures 
as  such,  but  uses  each  at  the  proper  time  and  in  its  proper 
place.  It  has  completely  emancipated  itself  from  its  for- 
mer rather  narrow  limits,  and  has  made  lately,  and  is 
still  making,  vast  progress  in  the  simplification  and 
proper  choice  of  methods;  it  is  also  making  contribu- 
tions of  value  to  medical  and  surgical  practice.  It  is 
this  progressive,  vital,  modern  orthopedic  surgery  that 
it  has  been  our  aim  to  present. 

No  specialty  has  more  devoted,  abler,  or  broader- 
minded  workers,  and  in  none  is  progress,  both  theoretical 
and  practical,  more  evident.  It  owes  an  enormous  debt 
to  physicians,  surgeons,  and  pathologists,  the  results  of 
whose  advanced  investigations  are  being  rapidly  assim- 
ilated. If  some  of  this  indebtedness  can  be  repaid  by 
making  the  practical  details  of  our  art  available  in  gen- 
eral practice,  the  aim  of  the  work  will  be  accomplished. 

H.  L.  T. 


CONTENTS 


GENERAL   PART 

PAGE 

Introduction 1 

History 1 

Classification 5 

Causation 6 

Congenital  deformities 6 

Birth  deformities 6 

Acquired  deformities 6 

Congenital  Crippling  Affections 8 

Nanism 8 

Gigantism 9 

Myxedema .10 

Chondrodystrophia 10 

Osteodystrophia 12 

Nutritional  Disorders 12 

Marasmus 12 

Rachitis 13 

Infantile  scurvy 17 

Hemophilia 18 

Gout 19 

Infections 20 

Syphilis 20 

Gonorrhea 24 

Purulent  and  other  infections 27 

Osteomyelitis 28 

Tuberculosis 34 

Diseases  op  Unknown  Origin 44 

Villous  arthritis 44 

Arthritis  deformans — osteoarthritis — Still's  disease     ....  45 

Toxic  osteoperiostitis 48 

Ostitis  deformans 50 

Hyperostosis  of  the  skull 50 

Ostitis  fibrosa 51 

Osteomalacia 52 

xi 


xii  CONTENTS 

PAGE 

Tumors  and  Cysts 53 

Tumors  of  cartilage 53 

Tumors  of  bone 54 

Myositis  ossificans 54 

Benign  bone  cysts 56 

Parasitic  bone  disease 59 

Malignant  Diseases 59 

Sarcoma 59 

HyperneiDhroma 60 

Carcinoma 61 

Myeloma 61 

Spontaneous  Fracture 61 

Ununited  Fracture 62 

Diseases  of  the  Nervous  System .        .63 

Peripheral 63 

Cerebral 64 

Spinal 65 

Trophic  joints 70 

Hysteria 70 

Examination  and  Diagnosis  in  Orthopedic  Practice        ...  71 

History  and  records 75 

Laboratory  aids 77 

Skiagraphy .78 

Prevention 79 

Prognosis 81 

Treatment  of  Underlying  Cause '82 

General  indications 82 

Special  indications .  83 

Complications 85 

Abscess  (pockets) 85 

Ankylosis 88 

Atrophy 89 

Treatment  op  Deformity 91 

Mechanical 92 

Operative 93 

Gymnastic 95 


SPECIAL   PART 

NECK  AND   TRUNK 

Deformities  of  the  Neck 101 

Congenital  torticollis 101 

Birth  (sterno-mastoid)  torticollis 101 


CONTENTS  xiii 

Deformities  of  the  Neck  {Continued)  page 

Dislocation  of  cervical  spine 105 

Wryneck  from  debility  and  rickets 105 

Acute  or  infectious  ("rheumatic")   torticollis 106 

Cervical  spondylitis  tuberculosa 107 

Cervical  spondylitis  deformans 107 

Spasmodic  torticollis 108 

Cervical  rib 108 

Chest  Deformities 109 

Congenital 110 

Fissures  and  defects 110 

Funnel  chest 110 

Rachitic Ill 

Deformities  secondary  to  spinal  affections 112 

Deformities  of  the  Spine 113 

Normal  postures 113 

Congenital  anomalies 117 

Acquired  deformities 119 

Antero-posterior  deviations 119 

Round  back  (round  shoulders) 119 

Lordosis  or  hollow  back 132 

Spondylolisthesis 134 

Lateral  deviations 135 

Scoliosis 135 

Congenital 136 

Acquired 137 

Habit  scoliosis 137 

Static  scoliosis    .        .        .        .        .        .        .        .162 

Scoliosis  due  to  collapse  of  lung      ....  162 

Scoliosis  due  to  palsy  of  trunk  muscles          .        .  164 

Scoliosis  due  to  disease  in  ornear  the  spinal  column  164 

Diseases  of  the  spinal  column          .        . 174 

Spondylitis  tuberculosa — Pott's  disease 174 

Tuberculous  erosion  of  spine  secondary  to  tuberculosis  of  the 

abdominal  glands 197 

Rachitic  spine 198 

Spondylitis  traumatica — Kiimmel's  disease  .....  199 

Typhoid  and  other  infections 200 

Progressive  ankylosis  of  the  spine 200 

Neurotic  spine 203 

DEFORMITIES  OF  THE  SHOULDER-GIRDLE  AND 
UPPER  EXTREMITY 

General 205 

Shoulder  Girdle 205 

Defects,  dislocation,  and  fractures  of  the  clavicle        ....  205 
2 


xiv  CONTENTS 

Shoulder  Girdle  (Continued)  page 

Deformities  of  the  scapula 207 

Bowed  scapula 207 

Congenital  elevation  of  the  scapula 208 

Forward  shoulders 209 

Prominent  and  flattened  scapula 210 

Winged  scapula 211 

Acute  osteomyelitis 211 

Deformities  of  the  shoulder 211 

Congenital  ankylosis  and  dislocation 211 

Axillary  web 211 

Birth  palsy 212 

Dangle  shoulder 213 

Recurrent  dislocation 214 

Fracture 217 

Bursitis 219 

Infections  and  trophic  changes 221 

Fibrous  ankylosis 221 

The  Arm 222 

Deformities  of  the  shaft  of  the  humerus 222 

Deformities  of  the  elbow 222 

Congenital  stiffness 222 

Loose  elbow 222 

Deformity  after  fracture 222 

Bursitis 224 

Infections  of  the  elbow  joint 224 

Deformities  of  the  forearm 226 

Congenital  defects  and  anomalies 226 

Deformity  after  fracture 227 

Deformities  of  the  wrist  and  hand          .......  227 

Congenital  dislocation 227 

Congenital  club-hand 227 

Hemiplegia  and  spastic  palsy 229 

Volkmann's  ischemic  paralysis 230 

Ganglion  of  the  wrist 232 

Disease  of  the  wrist  joint 232 

Deformities  of  the  fingers 233 

Defects  of  fingers,  webs,  redundant  digits 233 

Congenital  digitus  varus 234 

Drop  phalangette 234 

Stiffness  of  the  fingers 234 

Dupuytren's  contraction 235 

Trigger  finger 237 

Professional  cramps  and  neuroses 237 


CONTENTS  XV 


DEFORMITIES  OF   THE  PELVIC  GIRDLE  AND    LOWER 
EXTREMITY 

PAGE 

Affections  of  the  Pelvis 239 

Diseases  of  the  pelvic  bones 239 

Affections  of  the  sacro-ihac  joint 239 

Laxity  of  the  joint 239 

Displacement  of  the  joint 240 

Infections  of  the  joint 241 

Osteoarthritis ■  .        .        .        ,        .        .241 

Deformities  of  the  Lower  Extremity 245 

General  remarks 245 

The  hip 246 

Congenital  dislocation 246 

Coxa  vara 263 

Spastic  and  paralytic  contractions 268 

Coxitis  tuberculosa .        .  269 

Infections  of  the  joint 294 

Osteoarthritis 297 

Deformities  of  the  Leg 302 

Fracture  of  the  neck  of  the  femur 302 

Deformities  of  the  shaft  of  the  femur 303 

Congenital  anomalies        .     ■ 303 

Osteomyelitis      .        .        .        .        .        .        .        .        .        .        .  305 

Sarcoma 305 

Cysts 306 

Bowed  femur 306 

Deformities  of  the  knee 306 

Congenital  deformities 306 

Flexion 307 

Snapping  knee 308 

Hyperextension  (subluxation)  .        i 308 

Absence  of  patella 308 

Acquired  deformities  of  the  knee 309 

Acquired  genu  recurvatum 309 

Bursitis 309 

Prepatellar 309 

Pretibial 310 

Pretubercular 310 

Posterior 311 

Patella 311 

Rupture  of  ligaments 311 

Fracture 311 

Slipping  patella 311 

Tuberculosis 312 

Ankylosis 312 


xvi  CONTENTS 

Deformities  of  the  Leg  (Continued)  page 

Genu  valgum — knock-knee 313 

Paralytic  and  spastic  deformities 318 

Acute  synovitis 320 

Gonitis  tuberculosa — white  swelling 322 

Other  infections 330 

Gonorrhea 330 

Syphilis 330 

Pus 330 

Arthritis  deformans 331 

Osteoarthritis 331 

Villous  arthritis 332 

Lipoma 333 

Floating  bodies — ^joint  mice 333 

Injury  and  displacement  of  the  semilunar  cartilages          .  334 

Deformities  of  the  lower  leg — knee  to  ankle 335 

Congenital  deficiency 335 

Of  tibia .  335 

Of  fibula 336 

Bow-legs  and  genu  varum 337 

Anterior  curvature  of  the  tibia 340 

Recurvature  of  the  tibia 341 

Syphilitic  osteoperiostitis — saber-leg 342 

Paget's  disease 342 

Osteomyelitis , 343 

Tumors  and  cysts 343 

Rupture  of  the  plantaris  muscle      .        .        .        ....        .  344 

Angina  cruris — intermittent  claudication 344 

Varicose  veins  and  ulcers 345 

Deformities  of  the  ankle 345 

Weak  ankle 345 

Sprain 345 

Tuberculosis  of  the  ankle  and  tarsus 347 

Deformities  of  the  foot 350 

Physiological 350 

Classification 355 

Pes  varus  and  equino-varus 355 

Congenital 355 

Paralytic 365 

Pigeon-toes 365 

Pes  equinus 366 

Adaptive 366 

Paralytic  and  spastic 367 

Pes  valgus 371 

Congenital 371 

Pott's  fracture    .        .        .        .        .        .        .        .        .        •  371 


CONTENTS  xvii 

Deformities  of  the  Leg  (Continued)  page 

Static— flat-foot 371 

"Rheumatoid"  and  infectious 380 

Paralytic 380 

Dislocation  of  peroneal  tendons 381 

Pes  calcaneus  and  calcaneo-valgus 381 

Congenital 382 

Paralytic 382 

Pes  cavus 386 

Flail-foot 386 

Deformities  of  the  heel 386 

Achillobursitis  anterior 386 

Achillotenontitis 387 

Talalgia — osteophytes  of  os  calcis 387 

Deformities  of  the  tarsus  and  metatarsus              388 

Tenosynovitis 388 

Injuries 388 

Hump-foot 388 

Claw-foot 389 

Weakness  of  anterior  arch — -metatarsalgia — Morton's  toe          .  390 

Corns  and  calluses 391 

Chilblains 391 

Deformities  of  the  toes 392 

Congenital 392 

Hallux  valgus 393 

Hallux  varus 395 

Hallux  rigidus 395 

Ingrown  toe-nail 396 

Hammer  toe 396 

Trigger  toe 397 

TECHNIC 

Means  of  Increasing  and  Diminishing  Local  Pressure  .        .        .  402 

Means  of  Increasing  and  Restricting  Motion 402 

Bandaging 402 

Strapping 403 

Splinting — General 404 

Fixation  Splints 405 

Indications 405 

Mechanical  principles 405 

Material 409 

Plaster-of-Paris  splints  and  casts 409 

Footplates 418 

Celluloid 419 


xviii  CONTENTS 

Fixation  Splints — Material  (Continued)  page 

Leather 419 

Steel 420 

Adjustable  fixation  splints — correction  splints 423 

Suspension  and  suspension  splints 424 

Traction  and  traction  splints 426 

Restricted  motion  splints 429 

Splinting — Special 431 

Leg  splints 431 

Tarsus  and  ankle 431 

Knee 437 

Hip 446 

Pelvic  splints 457 

Arm  splints 457 

Spinal  splints 460 

Neck  splints 472 

LITERATURE 479 

INDEX .  489 


LIST  OF  ILLUSTEATIONS 


FIG.  PAGE 

Rodin's  "  Bronze  Age " Frontispiece 

1. — Gigantism  of  leg 9 

2. — Chondrodystrophic  dwarf 11 

3. — Rachitic  child 14 

4. — Rachitic  skeleton 15 

5. — Scorbutic  infant 17 

6. — Gouty  hand 20 

7. — Syphilitic  osteochondritis 21 

8. — Syphilitic  osteoperiostitis 22 

9. — Syphilitic  osteoperiostitis 23 

10. — Gonorrheal  wrist 25 

11. — Osteomyelitis 29 

12. — Osteomyelitis 30 

13. — ^Typhoid  ostitis 34 

14. — Tuberculous  focus  lower  end  of  femur 35 

15. — Ankylosis  after  tuberculous  disease  of  hip 36 

16. — Tuberculous  phalangitis 38 

17. — Tuberculosis  of  hip  and  spine 42 

18. — -Osteoarthritis  of  knee  and  hip 46 

19. — Juvenile  polyarthritis 48 

20. — Juvenile  polyarthritis .48 

21. — Toxic  osteoperiostitis 49 

22. — Ostitis  deformans           51 

23. — Ostitis  deformans           51 

24. — Osteomalacia 52 

25. — Benign  exostosis  lower  end  of  tibia 54 

26. — Myositis  ossificans 55 

27. — Myositis  ossificans,  local  form 56 

28. — Benign  cyst,  lower  end  of  tibia 57 

29. — Benign  cyst,  neck  of  femur 58 

30. — Sarcoma  of  femur 60 

31. — Deformities  following  poliomyelitis 67 

32. — Drop-foot  following  poliomyelitis 68 

33. — Taking  angle  of  flexion  with  lead  tape 76 

34. — ^Measuring  angle  of  flexion  with  goniometer 77 

xix 


XX  LIST    OF    ILLUSTEATIONS 


FIG 


PAGE 

35. — Mapping  sinus  with  skiagram  after  bismuth  injection     ...  87 

36. — Sterno-mastoid  torticoUis 102 

37. — Sterno-mastoid  torticollis 102 

38. — Bratz  splint  for  torticollis 104 

39.— Defect  of  ribs 110 

40. — Funnel  chest  and  pigeon  breast Ill 

41. — Normal  poise  in  walking 115 

42. — Correct  standing  posture 116 

43. — Asymmetrical  sacrum 118 

44. — Sacralization  of  fifth  lumbar  vertebra 118 

45. — Atonic  round  back .        .120 

46. — Round  back  of  adolescence 123 

47. — -Swimming  movement             126 

48. — Swimming  movement            .        . 126 

49. — Leg  raising 126 

50. — ^Trunk  raising 127 

51. — Trunk  raising,  hands  clasped  behind 127 

52. — Prone-resting  on  elbows .        •  128 

53. — Correction  of  round  back  by  knee  pressure 129 

54. — Self -correction  of  round  back  by  spinal  extension    .        .        .        .130 

55. — Retraction  of  head  against  resistance 131 

56. — Posture  correction — chest  against  wall 132 

57. — Lordosis  from  bowed  femora 133 

58. — Sebring  chair 140 

59. — Writing  posture 141 

60.- — Reading  posture 141 

61. — Scoliotic  spine 143 

62. — Right  dorsal  left  lumbar  scoliosis 146 

63. — Same  with  adhesive  strips  and  plumb  line 146 

64. — Same  bending  forward 147 

65. — Left  total  scoliosis .148 

66. — Correction  of  same  by  right  upward  left  downward  stretch    .        .148 

67. — Right  dorsal  scoliosis 150 

68. — Self-correction  by  side  pressure 151 

69. — Kyphoscoliosis 152 

70. — Kyi^hoscoliosis 152 

71. — Cervico-dorsal  scoliosis 153 

72. — -Same  bending  forward 154 

73. — Van  Winkle  corset  brace 158 

74. — Taylor's  lateral  suspension  apparatus 159 

75. — Lovett's  stretching  board      .        .        . 160 

76. — Plaster-of-Paris  corset 161 

77. — Scoliosis  from  empyema 163 

78. — Scoliosis  from  empyema 163 

79.— Modified  Hoffa  posture 168 

80. — Side  pressure 169 


LIST    OF    ILLUSTRATIONS  xxi 

FKi.                                                             •  PAGE 

81. — Side  pressure  with  side  bending 169 

82. — Creeping  posture 170 

83. — Creeping  posture 171 

84. — Lunge  posture 17.3 

85. — Psoas  abscess 170 

86. — Specimens  of  Pott's  disease 177 

87. — Posture  in  early  Pott's  disease 179 

88. — Lead  tape  tracing  of  early  Pott's  disease   .        .        .        .        .        .  180 

89. — ^Test  for  spinal  rigidity .181 

90. — Lateral  deviation  in  early  Pott's  disease    ...        .        .        .182 

91. — Pott's  disease  in  neck 184 

92. — LTpper  dorsal  Pott's  disease 185 

93. — Upper  lumbar  Pott's  disease 186 

94. — Perinephri tic  abscess 188 

95. — Whitman's  gas-pipe  frame 189 

96. — Plaster  jacket  with  jury  mast 190 

97. — Calot  jacket  without  head  support 191 

98. — Calot  jacket  with  head  support 192 

99. — Calot  jacket  with  head  support 192 

100. — ^Taylor  brace  with  head  support 193 

101. — Lower  lumbar  Pott's  disease — cured 194 

102. — Final  result  in  untreated  Pott's  disease 195 

103. — -Result  in  untreated  case  after  three  years 196 

104. — Result  after  five  years  of  support 197 

105. — Rachitic  spine 198 

106. — Correction  of  same  in  prone  posture .199 

107. — Specimens  of  osteoarthritis  of  spine 201 

108. — Ankylosing  arthritis  of  spine,  and  large  joints 202 

109.— Taylor  clavicle  splint 206 

110. — Taylor  clavicle  splint 206 

111. — Safety-pin  clavicle  dressing 207 

112. — Incisions  for  axillary  web 211 

113.— Obstetric  palsy 212 

114. — Burrell's  operation 216 

115. — Isolated  fracture  greater  tuberosity  of  humerus     .        .        .        .218 

116. — Isolated  fracture  greater  tuberosity  of  humerus        ....  219 

117. — Albee's  posture  for  juxta-epiphyseal  fracture  of  humerus       .        .  220 

118. — Detachment  of  external  condyle  of  humerus 223 

119.— Tuberculous  elbow 225 

120. — Absence  of  radius 226 

121.— Dislocation  of  hands 228 

122.— Wrist  splint 229 

123. — Ischemic  palsy 231 

124.— Web  fingers 233 

125. — Drop  phalangette 235 

126. — Dupuytren's  contraction 236 


xxii  LIST    OF    ILLUSTRATIONS 

FIG.  PAGE 

127. — Synostosis  of  iliac  joint 241 

128. — Strain  of  iliac  joint 242 

129. — Congenital  dislocation  of  hip 248 

130. — C'Ongenital  dislocation  of  hip 249 

131. — Congenital  dislocation  of  hip 251 

132. — Congenital  dislocation  of  hips,  cross-legged  progression  .       '.        .  252 

133. — Double  spica  after  reduction 260 

134. — Last  posture  after  reduction         .        .  - 261 

135. — Cervical  coxa  vara 264 

136. — Same  corrected,  after  operation  by  Whitman 265 

137. — Epiphyseal  coxa  vara 266 

138A. — Skiagram  of  beginning  coxitis 270 

138B. — Skiagram  of  advanced  coxitis 271 

139. — Tuberculous  erosion  of  acetabulum 272 

140. — Disease  of  great  trochanter 273 

141. — Disease  of  great  trochanter 274 

142. — ^Tuberculosis  of  femoral  neck 275 

143. — Ankylosis  after  coxitis .276 

144. — Testing  hip  hyperextension 277 

145. — ^Testing  hip  hyperextension 277 

146. — Beginning  coxitis 278 

147. — Adduction  and  flexion  of  thigh 279 

148.— Testing  flexion  of  left  hip 280 

149. — ^Testing  extension  of  left  hip 281 

150. — Traction  in  bed  with  weight  and  pulley 284 

151. — Traction  in  bed  with  weight  and  pulley 284 

152.— Phelps  hip  sphnt 285 

153. — Polyclinic  hip  sphnt,  with  adhesive  plaster  applied         .        .  286 

154. — Right-angle  flexion  after  coxitis 287 

155. — Result  after  forcible  correction 287 

156. — Result  after  Gant's  osteotomy .  289 

157. — Result  after  excision  of  hip 292 

158. — Natural  cure  of  coxitis 294 

159. — Disappearance   of  head  and   neck  of  femur   after   suppurative 

arthritis 296 

160.— Osteoarthritis  of  hip 298 

161. — Albee's  operation  for  osteoarthritis  of  hip 300 

162. — Albee's  operation  for  osteoarthritis 301 

163. — Congenital  short  leg 304 

164. — Congenital  flexion  of  knees           307 

165. — Knock-knees  and  bow-legs 314 

166. — Thomas's  knock-knee  brace 316 

167. — Osteotomy  above  the  condyles 317 

168. — Chronic  hydrops 321 

169. — ^Tuberculous  ostitis  of  knee  .        . 323 

170. — Thomas  knee  splint 326 


LIST    OF    ILLUSTKATIONS  xxiii 

FIG.  PAGE 

171. — Result  after  early  excision  of  knee 327 

172. — Result  after  early  excision  of  knee 327 

173. — Flexion  after  early  excision  of  knee 328 

174. — Charcot  knee 331 

175. — Congenital  absence  of  fibula 336 

176. — Knight  bow-leg  braces           .    ■ 337 

177. — Manual  osteoclasis 338 

178. — G rattan  osteoclast          .        .        .        .   ' 339 

179. — Tibial  recurvature  and  reversed  bow-legs 340 

180.— Saber-leg 341 

181. — Paget's  disease,  local  form 342 

182. — Chronic  osteomyelitis  of  tibia 343 

183.— Tuberculosis  of  ankle 348 

184. — Tuberculosis  of  ankle  and  tarsus 349 

185.— Normal  feet 350 

186.— Normal  shoes 351 

187. — Orthopedic  shoes 352 

188. — Sole  prints  of  normal  feet 353 

189. — Congenital  equino-varus 356 

190.— Untreated  club-foot 357 

191.— Untreated  club-feet 358 

192. — Plaster-of-Paris  splint  for  varus 359 

193.— Judson  splint 360 

194.— Taylor  method 361 

195. — Taylor  equino-varus  splint 362 

196.— Long  splint  for  club-foot 363 

197.— Correction  of  club-foot  with  Thomas  wrench 364 

198.— Pes  equinus 367 

199. — Tenotomes  and  osteotomes 368 

200.— Tenotomy  of  heel  cord 369 

201.— Ankle  braces 370 

202.— Weak  ankles 372 

203.— Weak  feet 372 

204.— Imprint  of  flat-foot 373 

205.— Thomas  heel 374 

206.— Strapping  of  flat-foot 376 

207.— Rigid  flat-foot 377 

208.— Flat-foot  plates 378 

209. — Manipulation  of  flat-foot  and  strapping  of  flat-foot         .        .        .  379 

210. — Paralytic  calcaneo-valgus 382 

211. — Paralytic  calcaneo-cavus 383 

212.— Schapp's  lever 385 

213. — Spurs  of  OS  calcis 387 

214. — Supernumerary  digits 392 

215. — Congenital  hypertrophy  of  toes    ........  393 

216.— Hallux  valgus 394 


GENERAL    PART 


Oethopedic  surgery  is  that  branch  of  medical  science 
which  studies  to  prevent,  alleviate,  or  correct  the  de- 
formities and  disabilities  of  the  bodily  framework. 

In  order  to  understand  physical  deformities  a  good 
working  knowledge  of  anatomy,  pathology,  and  general 
medicine,  including  neurology,  is  necessary,  and  for  suc- 
cessful treatment  one  should  know  hygiene,  elementary 
mechanical  principles,  corrective  gymnastics,  general 
therapeutics,  and  the  principles  and  practice  of  sur- 
gery. In  Germany,  orthopedic  surgery  until  recently 
has  not  paid  special  attention  to  underlying  causes,  but 
in  this  country  it  has  long  been  recognized  that  bone  and 
joint  diseases  produce  a  large  proportion  of  deformities, 
and  the  tendency  everywhere  is  to  include  their  manage- 
ment as  well  as  that  of  general  and  local  conditions 
affecting  bone  stability  and  muscular  power  in  the  larger 
conception  of  orthopedic  surgery.  Some  American  clinics 
even  assign  fractures  to  the  orthopedic  department,  as 
their  successful  management  largely  depends  upon  the 
correct  application  of  mechanical  principles  and  the 
manipulative  dexterity  which  should  distinguish  the  or- 
thopedic surgeon. 

HISTOEY 

The  term  orthopedic,  from  two  Greek  words,  meaning 
straight  and  a  child,  was  first  used  by  Andry  in  his  popu- 

3 


4  HISTORY 

lar  treatise  published  in  French  in  1741,  and  republished 
in  English  in  1743,  and  in  German  in  1744.  Many  authors 
before  and  since  have  described  deformities  and  crip- 
pling affections  and  their  treatment.  Percival  Pott  pub- 
lished his  discovery  of  the  relation  between  destructive 
disease  of  the  vertebrae  and  paraplegia  in  1779,  and  early 
in  the  nineteenth  century  French,  German,  and  English 
surgeons  made  important  contributions  to  our  knowledge 
of  deformities,  whose  treatment  received  great  impetus 
from  the  successful  introduction  of  subcutaneous  tenot- 
omy by  Strohmeyer  in  1831.  In  America  orthopedic  sur- 
gery became  an  independent  specialty  through  the  labors 
of  H.  G.  Davis,  Louis  A.  Sayre,  and  C.  Fayette  Taylor, 
who,  in  the  early  sixties,  placed  the  treatment  of  chronic 
joint  and  spinal  diseases  upon  a  sound  basis  by  devising 
efficient,  portative  apparatus  for  continuous  fixation  and 
traction.  In  the  last  twenty  years  there  has  been  a  renas- 
cence and  rapid  expansion  of  this  branch  both  in  Europe 
and  America.  Aseptic  surgery  has  made  operative 
interference  both  for  the  removal  of  disease  and  the 
correction  of  deformity  more  generally  applicable  and 
more  successful ;  at  the  same  time  the  technic  of  forcible 
manipulation  has  been  highly  developed  and  its  limits 
assigned.  To  these  has  been  added  the  discovery  of 
Roentgen,  which  reveals  the  size,  position,  and  struc- 
ture of  the  bones,  and  has  made  our  work  more  exact 
and  more  satisfactory.  Excellent  work  by  surgeons 
and  pathologists  has  been  utilized,  extending  the  scope 
of  the  specialty  beyond  its  former  rather  narrow 
limits,  and  making  possible  its  successful  application 
to  adults  as  well  as  children.     The  tendency  and  aim 


CLASSIFICATION  5 

of  the  best  modern  practice  is  toward  radical  results 
by  simple  methods. 

CLASSIFICATION 

Deformities  may  be  divided  into  congenital  and  ac- 
quired, according  as  they  develop  before  or  after  birth. 
The  deformities  due  to  injuries  at  birth  form  an  inter- 
mediate group,  usually  classed  with  the  acquired.  De- 
formities may  be  primary  or  secondary,  according  as  they 
are  directly  or  indirectly  due  to  injuries,  pathological 
processes,  general  or  local,  or  mechanical  influences. 

From  the  point  of  view  of  their  pathogenesis  de- 
formities may  be  divided  into  two  principal  classes  (Rie- 
dinger) : 

1.  Load  deformities,  caused  by  yielding  to  pressure  or 
superincumbent  weight.  The  overloading  may  be  trau- 
matic, constitutional,  static  (habitual),  or  pathological 
(secondary).  The  critical  factor  is  often  the  upright 
posture. 

2.  Contractures,  caused  by  shortening  of  the  tissues 
on  one  side  of  a  joint.  These  also  may  be  traumatic,  con- 
stitutional, habitual,  or  pathological. 

In  simpler  words,  when  the  structural  elements  of  a 
part  are  weakened  or  overloaded,  that  part  may  be 
pushed  or  pulled  out  of  place. 

Overgrowth,  underdevelopment,  wasting,  and  joint- 
looseness  may  also  be  considered  with  the  deformities. 

In  reacting  to  a  long-continued  deforming  force  the 
skeleton  behaves,  so  far  as  concerns  its  external  form,  like 
a  plastic  solid ;  it  suffers  condensation,  expansion,  and 
change  of  direction  in  various  parts.    Its  internal  struc- 


6  CAUSATION 

ture,  however,  shows  adaptation  to  change  of  stress 
(Wolff's  law).  In  those  parts  where  pressure  is  in- 
creased, the  structure  becomes  stronger  in  its  units  and 
in  its  arrangement;  in  parts  where  pressure  is  dimin- 
ished, the  structure  becomes  weaker.  Similar  adaptive 
changes  take  place  to  a  certain  extent  in  the  external  form 
of  the  bone,  as  in  the  filling  in  of  the  concave  side  of  a 
bow-leg.  The  soft  parts  also  undergo  structural  adapta- 
tion to  habitual  postures. 

CAUSATION 

Congenital  deformities  may  be  due  to  primary  defects 
or  nutritional  disturbances  in  the  germ  cells,  injuries  or 
diseases  in  utero,  amniotic  adhesions,  uterine  pressure 
from  deficiency  of  liquor  amnii,  and  other  causes.  The 
commonest  congenital  deformities  are  club-foot,  the  de- 
formities of  certain  spastic  palsies,  congenital  disloca- 
tion of  the  hip,  and  certain  anomalies,  deficiencies,  and 
redundancies  of  the  spine,  trunk,  and  extremities. 

Birth  deformities  caused  by  head  injuries,  brachial  plex- 
us, or  sterno-mastoid  tears,  and  fractures  of  the  long 
bones,  are  not  infrequent.  Injuries  to  nerves  or  centers 
often  lead  to  characteristic  palsies  and  contractures ;  in- 
juries to  muscles  and  bones,  if  untreated,  may  result  in 
serious  malpositions. 

Acquired  Deformities The  large  majority  of  children, 

however,  are  bom  without  blemish,  and  most  cripples 
acquire  their  deformity  after  birth  through  weakness, 
injury,  or  disease.  These  make  possible  displacement 
from  pressure,  the  pull  of  gravity,  or  contraction. 

1.  Weakness  from  any  cause,  especially  if  combined 


ACQUIRED   DEFORMITIES  7 

with  poor  hygiene,  too  much  standing  or  sitting,  monot- 
onous occui)ations,  and  faulty  postures,  is  a  common 
cause  of  flat  feet,  round  back,  and  lateral  curvature  of 
the  spine.  The  supporting  apparatus  for  one  cause  or 
another  is  inadequate  to  its  function,  and  sags  under  the 
superincumbent  weight.  The  weakness  may  be  an  ex- 
pression of  a  general  dyscrasia,  or  may  be  relative;  in- 
adequacy to  the  load. 

2.  Injuries  resulting  in  inflammation  or  cicatricial 
contractions  of  the  soft  parts ;  sprains,  fractures,  and  dis- 
locations are  frequent  causes  of  temporary  or  permanent 
deformities,  as  are  also  the  injuries  inflicted  by  certain 
postures  and  occupations,  and  by  improper  dress,  such  as 
tight  corsets,  and  short,  narrow,  or  pointed  shoes. 

3.  Most  important  of  all  in  producing  deformity  are 
the  changes  produced  by  disease,  affecting  especially: 

(a)  The  bones,  cartilage,  periosteum,  and  joints;  as 
rickets,  scurvy,  chondrodystrophia,  syphilis,  osteomye- 
litis, Paget's  disease,  arthritis  deformans,  tuberculosis, 
and  many  other  infectious,  trophic  disturbances,  and  new 
formations. 

(b)  The  bursas,  tendon  sheaths,  tendons,  and  fibrous 
tissue ;  of  which  gonorrhoea  is  a  frequent  and  often  unsus- 
pected cause.  Dupuytren's  finger  deformity  is  due  to 
fibrous  contraction.  Diseases  of  the  muscles,  as  myositis 
acute  and  chronic,  and  myositis  ossificans,  often  cause 
deformities  and  disabilities  of  considerable  importance. 

(c)  The  peripheral  or  central  nervous  system,  produc- 
ing stiff  or  flaccid  palsies,  or  pseudo-palsies,  often  with 
great  disability  and  deformity,  and  sometimes  joint  affec- 
tions, as  in  Charcot's  joint,  and  other  arthropathies. 


8  CAUSATION 

It  will  thus  be  seen  that  deformities  and  crippling 
affections  may  be  studied  from  the  standpoint  of  their 
causation,  from  that  of  the  tissue  affected,  or  from  that 
of  the  part  of  the  body  involved.  In  the  special  part  of 
this  work  each  part  of  the  body  is  passed  in  review  and 
its  principal  deformities  and  deforming  affections  are 
briefly  described.  In  order  to  save  repetition  and  to  em- 
phasize the  importance  in  many  cases  of  general  treat- 
ment directed  to  the  underlying  cause  or  pathological 
process,  the  principal  crippling  affections  are  hereinafter 
outlined. 

CONGENITAL  CRIPPLING  AFFECTIONS 

Local  congenital  affections,  like  congenital  club-foot 
and  congenital  dislocation  of  the  hip,  are  treated  under 
appropriate  sections  in  the  special  part. 

The  primary  intrauterine  diseases  which  seriously 
affect  the  skeleton  are  syphilis,  myxedema,  chondrodys- 
trophia,  and  osteodystrophia.  In  addition  nanism  and 
gigantism,  though  not  always  congenital,  may  for  con- 
venience be  considered  here. 

Nanism,  or  microsomia,  is  often  due  to  some  defect  of 
nutrition,  as  cretinism,  achondroplasia,  or  rickets.  Mi- 
cromelia  may  be  accompanied  by  imperfect  development 
of  one  or  more  of  the  long  bones ;  if  acquired,  it  may  be 
due  to  imperfect  use  or  imperfect  nutrition  from  local 
paralysis,  disease,  or  deformity.  Slight  differences  in 
the  length  of  the  legs  in  otherwise  normal  children  and 
adults,  not  otherwise  easily  explicable  than  as  primary 
defects  or  as  differences  in  the  rate  of  growth,  are  not 
infrequent. 


CONGENITAL    CRIPPLING   AFFECTIONS       9 

Gigantism. — When  the  whole  skeleton  is  markedly 
larger  than  normal,  the  condition  is  known  as  gigantism, 
or  macrosomia.  Most  marked  gigantism  is  pathological ; 
giants  are  usually  weak  and  of  poor  endurance,  often  with 


Fig.  1. — Gigantism  of  Left  Leg. 
(Hospital  for  the  Ruptured  and  Crippled.) 

round  back,  lateral  curvature,  and  other  malformations. 
Many  cases  are  supposed  to  be  caused  by  nutritional 
changes  due  to  affections  of  the  pituitary  body  in  the 
growing  period.    In  adults   similar  conditions  produce 


10  CAUSATION 

acromegaly.  Congenital  macromelia  affecting  the  lower 
extremity  or  a  part  of  it  is  occasionally  observed  (Fig. 
1).  Sometimes  a  gigantic  toe  may  require  removal.  Ac- 
quired macromelia  may  be  due  to  blocked  lymphatics, 
chronic  osteomyelitis,  and  syphilis  of  the  long  bones.  As 
in  micromelia,  a  difference  in  length  of  the  extremities 
may  require  additional  height  added  to  the  sole  of  the 
shorter  side,  to  level  the  pelvis  and  facilitate  walking. 

Congenital  syphilis  is  treated  in  the  same  section  as 
acquired. 

Myxedema,  or  cretinism,  is  a  disturbance  of  nutrition, 
which  is  often  congenital,  and  is  due  to  disease  or  de- 
ficiency of  the  thyroid  gland,  which  lessens  the  supply  of 
its  internal  secretion.  The  skin  is  dry  and  thick,  and  of 
a  yellowish  pallor,  the  hair  is  dry  and  brittle,  the  tongue, 
lips,  and  subcutaneous  tissues  are  thickened.  The  intel- 
lect is  dull  and  apathetic,  and  mental  and  bodily  growth 
are  much  dela^^ed.  The  bones  are  softer  than  normal, 
and  round  back  and  deformities  of  the  thorax  and  limbs 
resembling  rachitic  deformities  are  not  uncommon.  The 
exhibition  of  the  dried  thyroid  gland,  beginning  with  a 
grain  or  two  once  or  twice  a  day  for  infants,  and  increas- 
ing it  under  careful  watching  of  the  pulse,  in  nearly  all 
cases  effects  marvelous  improvement,  and,  if  long  enough 
continued,  a  complete  disappearance  of  the  symptoms. 
If  the  drug  is  withdrawn,  the  symptoms  return. 

Chondrodystrophia  fetalis  (achondroplasia)  was  formerly 
called  fetal  rickets,  but  is  an  entirely  distinct  disease, 
characterized  by  imperfect  development  of  cartilage  and 
of  bone  developed  from  cartilage.  The  epiphyses  of  the 
long  bones  fuse  early,  leading  to  retarded  growth  of  the 


CONGENITAL    CRIPPLING    AFFECTIONS     11 

extremities  and  dwariing.  The  bridge  of  the  nose  is  de- 
pressed, the  head  large,  the  trunk  long,  the  arms  and  legs 
are  very  short  and  thick,  and  their  growth  extremely 


Fig.    2. — Chondrodystrophic    Dwarf    Aged    Fourteen;    Hypertrophic 
Form.     Note  shortness  of  extremities. 

slow  (Fig,  2).  Curvatures  of  the  long  bones  and  round 
back  are  sometimes  present.  In  certain  cases  the  bony 
prominences  about  the  joints  are  greatly  hypertrophied, 


12  CAUSATION 

making  the  joints  ^'ery  large,  and  interfering  with  mo- 
tion; this  stiffness  may  affect  the  spine.  The  cause  is 
unknown  and  the  treatment  symptomatic. 

Osteodystrophia  fetaHs  ^  {osteogenesis  imperfecta,  peri- 
osteal dysplasia,  fragilitas  ossium). — This  disease  has 
also  been  called  erroneously  fetal  rickets.  "  Osteogenesis 
imperfecta  is  a  systemic  bone  disease,  which  .  .  .  attacks 
the  very  young  fetus,  and  .  .  .  prevents  or  disturbs  the 
normal  development  and  calcification  of  osteoid  tissue. 
Externally  the  disease  manifests  itself  by  defective  de- 
velopment of  the  cranial  vault  and  fragility  of  the  bones 
of  the  entire  skeleton"  (Nathan). 

The  osteogenetic  function  of  the  periosteum  is  very 
defective,  but  the  bones  grow  normally  in  length.  Re- 
peated fractures  from  trivial  causes  occur  in  infancy  and 
childhood ;  these  unite  readily  in  four  weeks.  The  cause 
of  the  disease  is  unknown  and  the  treatment  symptomatic. 
The  child  should  be  handled  with  great  care  to  avoid 
fractures,  and  when  these  occur  splints  should  be  care- 
fully adjusted  to  prevent  deformity.  These  children 
learn  to  walk  in  time,  and  after  puberty  the  bones  become 
less  brittle.    There  is  no  specific  treatment  of  the  process. 

NUTRITIONAL   DISORDERS 

Marasmus  is  a  disorder  of  infancy  in  which  the  body  is 
insufficiently  nourished.  It  is  characterized  by  weakness 
and  wasting,  but  is  wanting  in  the  specific  characters  of 
rickets.  These  children  are  late  in  holding  up  the  head, 
sitting,  standing,  and  walking,  and  often  develop  a  round 

>  Term  proposed  by  the  writer. 


NUTRITIONAL    DISORDERS  13 

back  when  seated,  which  resembles  rachitic  round  back. 
When  they  begin  to  walk  they  may  develop  fiat-foot  and 
leg  deformities.  Children  of  delicate  constitutions  and 
defective  development  may  develop  weak  feet  and  knock- 
knees,  usually  of  light  or  moderate  grade,  without  being 
either  marantic  or  rachitic.  The  marantic  cases  should 
be  kept  off  their  feet,  and,  if  necessary,  prevented  from 
sitting,  until  the  diet  has  been  regulated  and  the  nutrition 
improved.  Small  doses  of  thyroid  are  said  to  be  bene- 
ficial (Simpson).  If  deformity  should  still  persist,  it 
may  require  appropriate  local  management.  In  the  case 
of  delicate  children  a  mild  tonic  regimen,  with  open-air 
life  and  abundant  nourishment,  should  be  provided. 
Comparatively  mild  local  measures,  such  as  special  exer- 
cises, or  the  building  up  of  the  inner  border  of  the  shoes, 
will  usually  suffice  for  the  deformity.    See  special  part. 

Rachitis,  or  rickets,  the  most  frequent  if  not  the  most 
important  crippling  affection  of  infancy,  is  a  disease  of 
defective  nutrition  from  faulty  feeding,  affecting  all  the 
tissues ;  it  is  no  more  a  bone  disease  than  syphilis  is  a 
disease  of  the  skin.  Rickets  is  very  rife  among  the  ne- 
groes, Italians,  and  Oriental  Jews  of  New  York,  and 
exists  among  other  elements  of  the  population  in  pro- 
portion to  the  prevalence  of  errors  of  infant  feeding,  such 
as  the  feeding  of  cooked  milk,  condensed  milk,  artificial 
food,  mother's  milk  of  poor  quality,  due  to  illness,  insuf- 
ficient diet,  too  prolonged  nursing  (Fig.  3),  or  intercur- 
rent pregnancy;  or  the  feeding  of  substances  unsuited  to 
the  child's  age,  such  as  the  food  from  the  family  table, 
including  tea,  coffee,  beer,  and  wine.  A  frequent  error 
is  the  too  free  use  of  soup  and  cereals.    The  process  in 


14 


CAUSATION 


the  bone  consists  in  an  excessive  production  of  cartilage 
with  defective  calcification;  this  is  not  affected  by  giv- 
ing soluble  calcium  salts.    The  respiratory  and  intestinal 


Fig.  3. — Rachitic  Child  of  Two,  Nursing.     Note  the  large  ankle  bones. 

tracts  are  prone  to  catarrh.  The  sjTuptoms  of  rickets 
are  enlargement  of  the  juxta-epiphyseal  regions,  espe- 
cially at  the  wrists  and  ankles,  beading  at  the  costo- 
ehondral  junction  (rachitic  rosary),  Harrison's  grooves 


NUTRITIONAL   DISORDERS 


15 


at  the  sides  of  the  thorax,  square  forehead,  large  fonta- 
nelles,  head  sweating,  delayed  dentition,  weakness,  bowed 
back,  delayed  locomotion,  and  deformities,  particularly 
of  the  lower  extremities  and  dwarfing  (Fig.  4).    Rickets 


Fig.  4. — Skeleton  of  Rachitic  Dwarf — -Adult,  Showing  Multiple 
Deformities.     (Royal  College  of  Surgeons,  London,     Phelps.) 


16  CAUSATION 

is  a  disease  of  infancy  and  early  childhood;  it  usually 
begins  in  the  first  year,  and  seldom  starts  after  the  sec- 
ond. At  the  age  when  the  baby  should  sit  up,  the  flabby 
muscles  and  tissues  allow  the  body  to  sag,  and  the  back 
to  curve  backward;  when  the  child  begins  to  walk,  the 
softened  long  bones  bend  under  the  superincumbent 
weight,  giving  rise  to  bow-legs,  anterior  tibial  curves,  and 
knock-knees,  bending  at  the  femoral  neck,  and  other  de- 
formities (Figs.  57,  105,  106,  and  165).  Some  of  these 
deformities  may  also  be  produced  by  prolonged  sitting. 
In  severe  cases  the  children  may  not  walk  until  the 
fourth  year  or  later,  but  the  disease  is  usually  self- 
limited,  and  also  readily  cured  by  proper  feeding  and  the 
administration  of  digestible  fat,  either  animal  or  vege- 
table. In  the  prevention  of  deformity,  it  is  important 
that  the  child's  sitting,  standing,  and  walking  should  be 
limited,  and  enforced  recumbency  for  weeks  or  months 
is  sometimes  necessary.  The  bones  are  soft  during  the 
active  stage  of  the  disease ;  after  this  they  become  abnor- 
mally hard  and  brittle.  Rachitic  deformities  of  moderate 
grade  tend  to  disappear,  but  often  require  mechanical 
(brace)  treatment;  the  severer  deformities  of  the  limbs 
may  usually  be  corrected  by  osteoclasis  or  osteotomy. 

The  knock-knees,  bow-legs,  and  coxae  varse  of  adoles- 
cents are  probably  not  due  to  "  adolescent  rickets/'  but, 
like  their  flat-feet,  round-backs,  and  lateral  curvatures,  to 
an  exaggeration  of  the  normal  plasticity  of  the  tissues 
characteristic  of  the  age  of  puberty.  When  to  the  less- 
ened resistance  of  the  tissues  is  added  greatly  increased 
loading,  as  in  continuous  sitting  or  standing,  or  the 
carrying   of   heavy  packages,   in   the   case   of  grocery 


NUTRITIONAL   DISORDERS 


17 


boys  and  others,  the  yielding  of  the  tissues  is  easily 
understood. 

"  Senile  rickets  "  is  not  rickets,  but  a  disease  character- 
ized by  hypertrophy  of  the  skull  and  long  bones,  and 
bending  of  the  latter;  it  was  first  clearly  described  by 
Paget.    See  Ostitis  deformans. 

Infantile  scurvy  was  formerly  described  as  "  acute  rick- 
ets," but  has  nothing  to  do  with  rickets,  though  the  two 
diseases  may  coexist.    It  is  an  acute  or  subacute  specific 


Fig.  5. — Scurvy  from  Twice  Pasteurized  Milk;  Infant  Eight  Months. 
Note  posture  of  relaxation,  and  swelling  of  right  thigh  and  .both  legs. 
Cure  in  three  weeks  on  orange  juice  and  fresh  milk. 

affection  of  nutrition,  due  to  deficiency  of  raw  or  fresh 
food,  and  occurring  in  babies  from  six  to  eighteen 
months,  and  sometimes  older.  There  are  pains,  espe- 
cially in  the  legs,  sometimes  in  the  back,  and  on  being 
handled ;  there  are  often  tender  spots  and  swellings  near 
the  joints,  and  the  legs  may  move  but  little,  sometimes 


18  CAUSATION 

not  at  all  (pseudo-paralysis,  Fig.  5).  The  tenderness 
and  swelling  are  due  to  effusions  of  blood  under  the  peri- 
osteum. The  child  may  have  purplish  spots  on  the  skin, 
and  there  may  be  ulcerated  and  bleeding  gums  about  the 
teeth;  if  teeth  are  not  erupted,  the  gums  are  usually 
sound.  In  advanced  cases  the  skin  is  of  an  unwholesome 
grayish  color,  the  child  refuses  food,  and  often  has  some 
fever.  There  is  little  or  no  digestive  or  bowel  dis- 
turbance. The  child  is  fretful,  observant,  and  anxious. 
"When  the  artificial  food  or  condensed  milk  is  stopped 
and  a  suitable  uncooked  fresh  milk  mixture  given, 
and  the  strained  juice  of  one  orange  and  a  dessert- 
spoonful to  a  tablespoonful  of  fresh  meat  juice  ad- 
ministered daily,  the  symptoms  usually  disappear  in  a 
few  days.  "When  correctly  diagnosed  and  treated,  it 
is  one  of  the  most  curable  diseases  known.  Drugs  are 
superfluous. 

Hemophilia  and  Purpura. — ^Bleeders  not  infrequently 
have  effusions  of  blood  into  one  or  more  joints  after 
slight  injury,  and  sometimes  with  no  antecedent  trauma ; 
this  may  occur  in  early  infancy,  childhood,  or  early  adult 
life.  The  effusion  usually  takes  place  rapidly,  and  there 
may  be  at  first  little  pain,  but  if  distention  is  great  the 
pain  may  be  severe.  Tenderness,  stiffness,  and  disability 
are  less  marked  than  one  would  expect  from  the  pain  and 
swelling.  There  may  be  considerable  elevation  of  tem- 
perature at  first.  The  leucocyte  count  is  not  increased; 
the  withdrawal  of  sterile  blood  by  the  aspirator  estab- 
lishes the  diagnosis.  The  knee  is  the  joint  most  often 
first  invaded,  and  both  may  be  affected ;  other  joints  may 
be  involved  successively.     In  primary  cases  the  symp- 


NUTRITIONAL    DISORDERS  19 

toms  may  subside  within  a  week,  except  the  swelling  and 
limitation  of  motion,  which  may  remain  longer.  After 
repeated  hemorrhages  marked  changes  in  and  about  the 
joint  may  result;  these  sometimes  resemble  those  of 
arthritis  deformans,  and  occasionally  end  in  ankylosis. 
Subluxation,  or  lateral  mobility  at  the  knee,  may  occur 
from  stretching  of  the  capsule.  Even  in  the  recurrent 
cases  the  bone  is  not  thickened,  though  it  may  seem  so  to 
palpation.  The  diagnosis  is  of  critical  importance,  as 
several  deaths  from  bleeding  have  occurred  (two  under 
Konig)  after  opening  these  joints  under  the  mistaken 
diagnosis  of  tuberculosis.  In  making  the  diagnosis  the 
history  of  the  attack  and  the  previous  history  should  be 
carefully  considered.  The  treatment  is  immobilization, 
with  correction  of  deformity,  and  the  administration 
of  drugs  to  increase  coagulability,  such  as  gelatin,  or 
chlorid,  citrate  or  lactate  of  calcium  gr.  xx  to  xxx  sev- 
eral times  a  day,  or  of  thymus  or  suprarenal  gland.  The 
possibility  of  syphilis  as  a  cause  should  be  considered. 
Aspiration  not  only  clears  up  the  diagnosis,  but  may 
exert  a  favorable  effect  by  relieving  tension.  A  bleeder's 
joint  should  never  be  incised;  though,  according  to  Lo- 
brazes  and  Weil,  the  subcutaneous  or  intravenous  injec- 
tion of  20  c.c.  of  fresh  human,  horse,  or  rabbit  serum, 
or  even  antidiphtheritic  serum,  makes  operations  on 
hemophiles  safe.  The  procedure  may  be  repeated  every 
three  months  as  a  curative  measure. 

True  articular  gout  with  deposits  of  urates  is  rare 
in  America  (Fig.  6).  What  usually  passes  for  gout, 
whether  in  the  joints  or  other  structures,  is  either  arthri- 
tis deformans  or  the  result  of  infection  or  autointox- 


20 


CAUSATION 


ication.     In   articular  gout  the   skiagraiohic  picture  of 
the  bones  is  not  changed,  unless  urates  are  deiDOsited 


Fig.  6. — Gouty  Hand.     (After  Fisk.) 

in   sufficient   quantity   to   cause   local    absorption   from 
pressure. 


INFECTIONS   OF   BONES  AND   JOINTS 

Syphilis. — Considering  the  wide  prevalence  of  syphilis, 
the  limited  number  of  syphilitic  bone  and  joint  diseases 
seen  in  our  large  orthopedic  clinics  is  rather  remarkable. 


INFECTIONS    OF    BONES   AND   JOINTS      21 

The  syphilitic  baby  of  literature  is  a  puny,  wrinkled  spec- 
imen, bearing-  certain  stigmata;  such  babies  present  little 


Fig.   7. — Osteochondritis,  Two  Years'  Duration  in  a  Boy  of  Eight; 
Inherited  Syphilis.     (Hospital  for  the  Ruptured  and  Crippled.) 


difficulty  in  diagnosis,  but  it  should  be  borne  in  mind  that 
some  babies  who  afterwards  develop  characteristic  lesions 


Fig.  8.— Syphilitic  Osteoperiostitis  of  Tibia;  Inherited. 
Note  fallen  bridge  of  nose.     (Hospital  for  the  Ruptured  and  Crippled.) 
22 


INFECTIONS    OF    BONES    AND    JOINTS      23 


are  perfectly  normal  in  appearance  at  birth  and  subse- 
quently. Hereditary  bone  syphilis  in  infants  often  takes 
the  form  of  an  osteochon- 
dritis of  an  epiphysis,  with 
pain,  swelling,  and  some- 
times effusion ;  the  knee  and 
elbow  are  specially  vulner- 
able, and  the  affection  is 
often  polyarticular  (Fig.  7) ; 
the  process,  if  unchecked, 
may  result  in  local  destruc- 
tion or  epiphyseal  separa- 
tion. In  older  children  a 
persistent  unilateral  or  bi- 
lateral hydrops  of  the  knee, 
a  tardy  manifestation  of 
hereditary  lues,  may  clear 
up  on  mixed  treatment; 
such  a  condition  may  also 
be  due  to  chronic  tubercu- 
lous synovitis,  but  is  then 
refractory  to  specific  treat- 
ment. Hereditary  or  ac- 
quired bone  lesions  may  be 
due  to  an  osteoperiostitis 
(Figs.  8  and  9),  with  pain, 

tenderness,  and  overgrowth  of  bone  in  thickness  and 
length,  or  to  gummata  involving  bones  and  joints. 

We  occasionally  see  in  children  the  elongated  saber- 
like  tibiae  resulting  from  a  chronic  specific  osteoperiosti- 
tis (Fig.  180),  and  multiple  bony  swellings  of  unmistak- 


FiG.  9.  —  Osteoperiostitis  from 
Inherited  Syphilis  in  a  Girl 
OF  Seven.  Notice  the  "bone 
blisters." 


24  CAUSATION 

able  significance  usually  near  joints.  Phalangitis  syphil- 
itica is  characterized  by  more  thickening  of  the  cortex 
and  less  tendency  to  involve  the  joint  than  phalangitis 
tuberculosa,  which  is  much  more  frequent.  We  also 
see  occasionally  a  bone  or  joint  lesion  whose  character 
is  revealed  by  the  coexistence  of  some  active  specific 
lesion  like  a  syphilitic  testicle,  or  which  may  be  suspicious 
from  the  history,  and  which  improves  or  clears  up  on 
mercury  or  mixed  treatment.  It  should  be  borne  in  mind 
that  all  lesions  in  syphilitics  are  not  specific,  especially 
when  the  syphilis  is  ancient,  and  also  that  with  lesions 
evidently  syphilitic  either  in  a  child  or  in  an  adult,  the 
history  may  be  entirely  and  truthfully  negative.  One 
should  always  be  on  the  lookout  for  bone  and  joint  syph- 
ilis, since  the  diagnosis  is  important,  but  such  cases  are 
not  verj^  common.  The  old-fashioned  mixed  treatment 
(Hydrargyri  bichloridi  gr.  ■^,  potassii  iodidi  gr.  v,  aquae 
ad.  oj,  t.  i.  d.  for  an  adult)  has  been  most  efficient  and  will 
occasionally  clear  up  an  obstinate  or  doubtful  case  like 
magic.  In  some  cases  inunctions  of  unguentum  hydrar- 
gyri will  act  better.  Babies  may  be  treated  by  inunc- 
tions, by  small  doses  of  calomel,  or  by  gray  powder  gr. 
ss.-gr.  j.,  b.  i.  d. 

Gonorrhea,  on  the  other  hand,  is  a  very  frequent  cause 
of  articular  and  periarticular  inflammation,  and  even  of 
ostitis  and  periostitis.  The  cause  is  usually  overlooked, 
except  in  the  form  miscalled  gonorrheal  rheumatism. 
Joint  infection  occurs  in  over  ten  per  cent  of  the  cases, 
and  may  take  place  at  any  stage  of  the  disease,  even  when 
latent  in  the  seminal  vesicles,  prostate,  or  uterine  ad- 
nexse;  endocarditis  is  also  common.    The  mildest  cases, 


INFECTIONS    OF    BONES    AND    JOINTS      25 

lasting  only  a  few  weeks,  may  be  caused  by  the  irritation 
of  bacterial  products ;  tliese  form  about  one  third  of  the 
cases.  In  others  the  pain  is  severe  and  may  be  agonizing, 
the  effusion  is  great,  and  there  is  a  tendency  to  the  in- 
volvement of  the  bursae,  tendon  sheaths,  and  periarticu- 


FiG.  10. — Gonorrheal  Arthritis  of  Right  Wrist  in  Adult. 
Note  atrophy,  blurring  of  lines,  and  obliteration  of  joint  spaces. 


lar  structures.  The  constitutional  symptoms  are  moder- 
ate, and  there  is  not  much  tendenc}^  to  metastasis  from 
the  affected  joints.  According  to  Nathan,  the  infection 
is  essentially  acute,  and  involves  either  the  bone  or  the 
joint  primarily  (Fig,  10),  If  a'primary  osteomyelitis,  the 
X-ray  reveals  bone  atrophy  within  a  week,  and  the  joint 
may  become  secondarily  involved.     The  cases  primarily 


26  CAUSATION 

arthritic  remain  confined  to  the  joint,  and  do  not  involve 
the  bone  secondarily.  The  cases  which  pass  for  chronic 
are  said  to  be  either  cases  of  repeated  infections,  or  else 
there  is  no  active  gonorrheal  process,  the  irritation  being 
kept  up  by  repeated  insults  to  deformed  or  defective 
parts.  In  nearly  half  the  cases  the  trouble  is  mon- 
articular, and  in  the  polyarticular  form  fewer  joints  are 
affected  than  in  acute  rheumatism,  and  the  tendency  to 
skip  from  one  joint  to  another  is  lacking.  The  larger 
joints  are  most  frequently  affected,  particularly  the  knee, 
wrist,  hip,  ankle,  and  elbow,  but  the  smaller  joints  do  not 
always  escape;  even  the  temporo-maxillary  articulation 
and  the  spine  may  be  affected.  In  certain  cases  the  dis- 
ease can  hardly  be  distinguished  clinically  or  by  X-ray 
from  arthritis  deformans.  It  should  be  remembered  that 
when  the  blood  is  infected,  local  trauma  predisposes  to 
arthritic  infection.  The  puerperium  also  is  a  time  when 
the  susceptibility  of  the  patient  is  enhanced,  and  many 
joint  and  other  affections  which  have  passed  for  puer- 
peral sepsis,  are  really  due  to  gonorrhea,  which  may  have 
been  masked  or  latent.  In  spite  of  the  feeble  vitality  of 
the  gonococcus  outside  the  body,  the  specific  conjunctivi- 
tis and  vaginitis  is  extremely  contagious,  especially  in 
children  and  in  hospitals,  as  pointed  out  by  Holt.  Vulvo- 
vaginitis should  always  be  looked  for  and  excluded  from 
children's  wards.  In  this  form  joint  complications  are 
extremely  common,  and  usually  serious.  The  serous 
effusions  usually  subside  under  bandaging  and  rest,  but 
aspiration  is  occasionally  necessary.  Fibrinous  exuda- 
tion and  periarticular  involvement  tend  to  limitation  of 
motion,  the  formation  of  adhesions,  and  ankylosis ;  trac- 


INFECTIONS    OF    BONES    AND    JOINTS      27 

tion  or  splinting  may  be  required  in  the  active  stages, 
and  passive  and  active  movements,  and  sometimes  forci- 
ble correction,  after  recovery  from  the  acute  symptoms. 
It  is  usually  possible  to  prevent  deformity  in  early  cases. 

Many  cases  of  stiff  spine  in  young  men  are  due  to 
gonorrheal  infection.  Cases  of  flat  or  painful  feet  char- 
acterized by  points  of  acute  tend^erness  under,  at  the 
sides,  or  behind  the  heel,  over  the  plantar  fascia,  or  about 
the  mid-tarsus,  sometimes  with  enlargement  of  the  os- 
calcis  or  boggy  swelling  about  the  heel,  mid-foot,  or  fore- 
foot, and  very  resistant  to  shoe,  strapping,  and  plate 
treatment,  are  often  of  gonorrheal  origin.  The  forma- 
tion of  osteophytes  under  the  os  calcis,  sometimes  requir- 
ing excision,  is  not  uncommon.  Indeed,  when  a  flat-foot 
is  specially  obstinate,  particularly  if  unilateral,  gonor- 
rheal infection  should  always  be  considered. 

Perhaps  most  important  of  all,  and  this  we  are  only 
just  beginning  to  appreciate,  is  the  cure  of  the  original 
point  of  infection,  be  it  in  the  deep  urethra,  in  the  seminal 
vesicles,  in  the  vagina,  uterine  adnexa,  or  elsewhere. 
Magical  results  are  reported  from  attention  to  obscure 
sources  of  infection  (Fuller).  Encouraging  reports  are 
also  given  from  the  use  of  a  bactericidal  serum  (Rogers). 

After  the  subsidence  of  inflammation,  deformities 
should  be  corrected,  motion  restored,  and  disabilities  re- 
moved by  appropriate  orthopedic  treatment. 

Acute  (pus)  infection  of  bone  and  joints  is  not  uncom- 
mon. The  purulent  epiphysitis  and  arthritis  of  infancy, 
affecting  principally  the  hip,  knee,  or  shoulder,  may  be 
an  infection  from  the  navel  (phlebitis)  or  other  source. 
If  recognized  early  and  treated  by  free  incision,  removal 


28  CAUSATION 

of  dead  bone,  when  present,  irrigation  and  drainage,  the 
results  are  good.  If  neglected,  a  certain  nnmljer  of  joints 
open  spontaneously  and  recover,  sometimes  with  exten- 
sive destruction  of  bone  (Fig.  159) ;  l)ut  many  untreated 
cases  succumb  to  sepsis. 

Pus  joints  should  be  opened,  irrigated,  and  drained, 
and  during  repair  should  be  kept  at  rest  in  a  splint. 

Other  forms  of  pus  infection  are  acute,  subacute,  and 
chronic  osteomyelitis. 

Acute  osteomyelitis  is  most  frequent  in  early  life,  and  is 
usually  due  to  the  staph^^lococcus  aureus,  though  it  is 
sometimes  caused  by  streptococci,  pneumococci,  typhoid 
bacilli,  and  other  organisms.  Fatigue,  exposure  to  cold 
and  wet,  trauma,  and  acute  infectious  disease  are  predis- 
posing causes.  Fractured  bones,  particularly  compound 
fractures,  may  become  involved  in  a  local  osteomyelitis. 
The  usual  location  is  near  the  ends  of  the  long  bones,  out- 
side of  the  epiphysis  (metaphysis),  and  the  process  be- 
gins and  spreads  rapidly  in  the  marrow,  the  bone  becom- 
ing involved  secondarily.  When  the  bone  is  perforated, 
an  abscess  is  formed  which  may  elevate  the  periosteum ; 
this  is  one  cause  of  purulent  periostitis.  The  formation 
of  sequestra  surrounded  by  thick  and  irregular  bone  (in- 
volucrum)  is  a  characteristic  end  result  (Fig.  11),  but 
this  does  not  always  occur. 

Symptoms. — The  invasion  is  rapid  and  the  constitu- 
tional symptoms  are  severe.  Local  pain  and  tenderness 
are  intense,  and  if  the  bone  is  superficial,  heat,  redness, 
and  swelling  may  soon  be  detected.  The  process  may  go 
on  to  the  burrowing  or  rupture  of  an  abscess  (Fig.  12), 
or,  if  the  pus  does  not  perforate  the  bone,  the  toxemia 


Fig.  11. — Osteomyelitis  of  Tibia  at  Left,  of  Femur  at  Right.  Both 
show  a  sequestrum,  partially  covered  by  a  perforated  involucrum. 
(Specimens  from  College  of  Physicians  and  Surgeons,  New  York.) 

29 


30  CAUSATION 

may  increase  and  the  patient  may  die  in  stupor  or  de- 
lirium. In  some  (subacute)  cases  the  process  goes  on 
more  slowly,  with  less  urgent  symptoms.    In  young  chil- 


FiG.  12. — Circumscribed  Osteomyelitis  of  Shaft  of  Tibia 
WITH  Sequestrum  and  Sinus. 

dren  who  do  not  localize  pain  well,  a  tender  spot  may 
often  be  found  by  systematic  search. 

Diagnosis. — Syphilitic  and  tuberculous  bone  and  joint 
disease,  typhoid  fever,  meningitis,  acute  rheumatism,  and 
abscess  of  the  soft  parts  are  the  affections  most  often 
confounded  with  acute  osteomyelitis. 


INFECTIONS    OF    BONES    AND    JOINTS      31 

The  pKOGNosis  in  severe  cases  is  very  serious  unless 
relief  is  promptly  afforded;  the  patient  may  die  of 
septicemia  in  a  few  days,  or  of  pyemia,  ulcerative 
endocarditis,  or  exhaustion  later.  Suj^purative  arthritis 
in  a  neighboring  joint,  or  multiple  foci,  add  to  the  grav- 
ity of  the  disease.  Other  cases  progress  more  slowly 
to  rupture  or  incision  of  the  abscess,  and  a  chronic 
suppurative  process  with  sequestra,  sinuses,  and  vari- 
ous deformities  due  to  overgrowth,  retarded  growth, 
or  destruction  of  bone,  and  involvement  of  neighbor- 
ing joints.  Many  cases  are  saved  by  a  timely  oper- 
ation. 

Treatment. — Operative  interference  to  provide  ample 
drainage  of  the  medulla  is  urgently  needed  in  the  acute 
cases.  At  the  operation  the  periosteum  may  be  found 
elevated  from  the  whitish  bare  bone  by  creamy  pus.  If 
dots  of  pus  are  seen  coming  from  osteal  vessels,  or  if  fat 
globules  float  on  the  pus,  this  is  proof  of  suppuration  in- 
side the  bone.  At  this  operation  the  periosteum  should 
be  divided  and  separated  and  the  whitish,  bare  bone  chis- 
eled away  so  as  to  freely  expose  the  diseased  medulla 
throughout  its  extent;  obviously  diseased  or  infected  tis- 
sues should  be  removed,  but  the  medullary  cavity  should 
not  be  too  vigorously  scraped,  as  it  is  important  to  pre- 
serve both  the  periosteum  and  endosteum,  from  which 
new  bone  is  developed.  Many  surgeons  lay  great  stress 
upon  swabbing  out  with  various  antiseptic  solutions,  such 
as  pure  carbolic  acid,  followed  by  alcohol,  or  tincture  of 
iodine;  but  it  is  doubtful  if  they  are  better  than  mild 
cleansing  solutions.  In  the  milder  cases  it  is  sometimes 
well  to  close  the  wound  up,  and  occasionally  readhesion 


32  CAUSATION 

of  the  periosteum  and  primary  healing  take  place.  It  is 
usually  safer  to  pack  the  bone  with  gauze  for  twenty-four 
hours,  and  then  to  provide  wick  drainage  down  to,  but 
not  into,  the  bone  for  a  shorter  or  longer  time,  as  may  be 
necessary  (McCurdy) ;  this  favors  healing  by  granula- 
tion, and  a  considerable  number  of  such  cases  heal,  if 
they  do  not  become  reinfected.  Often  a  mild  infection 
ensues,  and  an  involucrum  of  ossifying  tissue  is  formed 
around  a  sequestrum.  This  will  become  sufficiently  de- 
veloped in  three  or  four  months,  when  it  should  be  split 
and  opened  for  the  removal  of  dead  bone;  the  cavity  is 
then  scraped  and  cleansed.  If  only  part  of  the  thickness 
of  the  shaft  is  removed,  the  involucrum  may  be  turned 
into  the  cavity  and  nailed.  If  the  whole  circumference 
of  the  shaft  is  removed,  the  involucrum  may  be  folded 
and  stitched  together  to  obliterate  the  cavity  (Nichols). 
The  involucrum  should  only  be  treated  in  this  manner 
when  it  is  fairly  certain  that  all  diseased  tissue  has  been 
removed.  In  very  extensive  cases  nearly  or  quite  the 
whole  shaft  may  have  to  be  removed  subperiosteally,  but 
this  should  not  be  done  unless  it  is  evident  that  the  shaft 
is  dead.  Complete  regeneration  of  the  shaft  of  a  long  bone 
from  the  periosteum  has  often  been  observed.  In  cases 
where  the  bone  focus  is  small  and  well  defined  it  is  often 
well  after  scraping  and  cleansing  the  cavity  to  fill  it  with 
Mosetig-Moorhof's  bone  wax,^  which  serves  as  a  scaffold 
for  the  granulations,  and  is  gradually  absorbed.    When 

1  Sixty  parts  iodoform,  forty  parts  each  of  spermaceti  and  oil  of  sesame; 
the  two  latter  are  melted  together,  the  iodoform  added  and  the  mixture  heated 
to  150°  on  a  water  bath  an  hour;  it  is  then  cooled  to  120°  and  poured  into  the 
cavity  at  that  temperature;  or  it  may  be  allowed  to  become  semisolid  and  may 
be  pressed  into  the  cavity;  it  becomes  solid  at  the  body  temperature. 


INFECTIONS    OF    BONES    AND    JOINTS      33 

this  is  used  the  operation  wound  may  be  closed,  though  it 
frequently  breaks  down. 

In  the  after  treatment  plaster-of-Paris  splints,  with 
windows  or  brackets,  or  wire  splints,  should  be  used,  and 
the  patient  kept  in  bed  until  healing  is  well  advanced. 
Ample  supplies  of  fresh  air  day  and  night  and  a  gener- 
ous diet  facilitate  repair.  If  bone  regeneration  is  insuf- 
ficient, osteoplasty  or  bone-grafting  may  be  indicated. 
The  process  of  repair  often  lasts  many  months. 

Chronic  Osteomyelitis. — Osteomyelitis  may  be  exceed- 
ingly chronic,  may  be  multiple,  and  even  symmetrical 
in  location,  and  may  simulate  rheumatism.  The  X-ray 
will  often  clear  up  the  diagnosis,  and  enable  the  surgeon 
to  remove  the  diseased  focus. 

Infectious  Arthritis.^The  ordinary  pus  microbes  are 
not  the  only  ones  that  may  cause  a  joint,  or  even  a  pus 
infection.  All  the  acute  infectious  diseases,  such  as  pneu- 
monia, influenza,  measles,  scarlatina,  typhoid  fever  (Fig. 
13),  and  the  rest,  are  capable  of  exciting  bone  and  joint 
inflammation,  sometimes  with  the  formation  of  pus. 
These  arthritides,  excited  by  the  toxins  or  bacteria  of 
the  acute  infectious  diseases,  have  often  passed  for  rheu- 
matism or  for  a  tuberculous  infection,  but  should  be 
sharply  distinguished  from  both.  The  term  infectious 
arthritis,  proposed  by  Goldthwait,  is  a  convenient  one  to 
separate  these  cases  in  practice.  When  a  joint  infection 
occurs  during  or  soon  after  an  acute  infectious  disease, 
the  possibility  of  a  specific  irritation  and  infection  should 
be  considered,  and,  when  possible,  the  fluids  or  tissues  ex- 
amined bacteriologically.  It  should  be  remembered,  how- 
ever, that  the  resistance  of  the  individual  cells  and  of  the 


34  CAUSATION 

system  is  weakened  after  such  diseases,  making  easier 
the  local  proliferation  of  pus  germs,  which  are  always 


Fig.  13. — Ostitis  op  the  Tibia  with  Small  Abscess,  Nineteen  Months 
AFTER  Being  Hit  by  Baseball,  Some  Months  after  Typhoid  Fever. 
Boy  of  eighteen. 

present.  This  is  also  true  of  tuberculous  infection,  which 
often  occurs  after  whooping  cough,  measles,  and  other 
depressing  diseases. 

Tuberculosis. — After  all  is  said,  the  large  majority  of 
chronic  joint  diseases,  particularly  in  children,  are  tuber- 


INFECTIONS    OF    BONES    AND    JOINTS      35 

culous.     There  are  many  hip,  knee,  and  ankle  diseases, 
but  the  typical  and  usual  one  is  tuberculous. 

Pathological  Anatomy. — The  tuberculous  process  in 
bones  and  joints  is  due  to  the  proliferation  of  the  tubercle 
bacillus,  which  excites  a  granulation  of  low  vitality  de- 
structive to  adjacent  bone,  but  with  a  definite  tendency 


Fig.  14. — ^Tuberculous  Focus  in  Left  Internal  Condyle  (Reversed) 
IN  Woman  of  Twenty-four.  Symptoms  at  times  for  fifteen  years 
following  a  fall.  Knee  flexed  and  stiff,  tender  spot  over  internal  condyle. 
Note  large  bullet-shaped  focus,  absence  of  joint  space,  and  atrophy  of 
bone. 


to  heal  by  encapsulation,  calcification,  or  cicatrization. 
The  tuberculous  infection  of  bones  and  joints  is  usually 
secondary  to  glandular,  or  other,  involvement  (Konig), 


36  CAUSATION 

though  in  most  cases  clinically  the  disease  seems  soli- 
tary. The  infecting  material  is  usually  carried  by  the 
blood  current,  and  commonly  lodges  in  the  very  vascular 
epiphyses  of  the  young.    Here  it  may  assume  the  form 


Fig.  15. — Bony  Ankylosis  Following  Tuberculosis  of  the  Hip. 
(Royal  College  of  Surgeons,  London.     Phelps.) 

of  one  or  more  small,  rounded  foci  (Fig.  14),  of  a  wedge- 
shaped  infarct,  extending  to  the  joint  surface,  or  of  a 


INFECTIONS    OF    BONES    AND    JOINTS      37 

diffuse  infiltration.  Small  foci  may  cicatrize,  or  break 
outward,  but  usually  erode  into  and  infect  the  neigh- 
boring joint.  The  process  often  ends  in  bone  destruction 
with  deformity  and  stiffness,  sometimes  in  true  bony 
ankylosis  (Fig.  15).  Small  sequestra,  cheesy  masses,  or 
collections  of  ichor  ^  may  be  formed.  In  certain  cases 
the  infection  is  primarily  synovial,  with  production  of 
serum,  fibrin  (rarely  sterile  pus),  and  pulpy  degenera- 
tion ;  in  such  cases  the  cartilage  may  resist  infection  and 
keep  itself  and  the  bone  intact  (Nathan) ;  in  others  the 
cartilage  and  bone  are  eroded  by  the  organization  of  de- 
posits of  fibrin.  Rarely  the  tuberculous  process  is  local- 
ized in  the  shaft  of  a  long  bone.  The  diseased  and 
swollen  phalanges  (spina  ventosse),  formerly  considered 
syphilitic,  are,  in  the  vast  majority  of  cases,  tuberculous. 
Phalangitis  tuberculosa  is  characterized  by  thinning,  ex- 
pansion, and  destruction  of  bone  and  early  involvement 
of  neighboring  joints  (Fig.  16). 

The  danger  of  infecting  others  from  a  tuberculous 
joint  is  remote  and  probably  negligible.  It  has  seemed  to 
the  writer  that  there  was  marked  antagonism  between 
active  rickets  and  joint  tuberculosis,  since,  while  both  are 
common  in  early  childhood,  their  coincidence  is  rare. 

Etiology. — Too  much  emphasis  should  not  be  placed 
on  the  personal  or  family  history,  which  is  often  unreli- 
able, and  is  never  decisive.  It  is  true  that  bone  tubercu- 
losis very  often  occurs  in  delicate  children  of  tuberculous 
antecedents,  prone  to  catarrhal,  digestive,  and  glandular 

*  The  term  ichor,  suggested  by  A.  Rose,  is  used  to  designate  the  thin  fluid 
with  flocculi  and  debris,  which  often  comes  from  tuberculous  foci  but  is  in 
no  strict  sense  pus. 


38  CAUSATION 

troubles,  formerly  called  scrofulous ;  but  such  constitu- 
tions are  quite  as  apt  to  come  from  alcoholic  or  neurotic 
parentage,  and  may  result  from  a  vicious  environment. 
In  a  word,  the  absence  of  tuberculosis  in  the  family  by 


Fig.  16. — Tuberculous  Phalangitis;  Three  Months'  Duration; 
Cure  after  Curettage  by  Albee. 

no  means  protects  the  child  from  infection,  nor  should  a 
tuberculous  family  history  cause  one  to  diagnose  a  pres- 
ent joint  affection  as  tuberculous.     The  history  is  one 


INFECTIONS    OF    BONES    AND    JOINTS      39 

factor  in  the  case,  often  a  minor  one,  and  to  be  at  all  com- 
plete it  must  include  information  as  to  alcoholism  and 
neuroses,  and  possibly  syj)hilis,  and  especially  as  to  ex- 
posure to  tuberculous  infection  in  the  dwelling,  whether 
from  a  relative  or  other  person.  Trauma  may  or  may 
not  be  an  exciting  cause,  and  may  in  particular  determine, 
or  more  probably  unmask,  the  localization  of  the  destruc- 
tive process.  A  trauma  of  moderate  severity  is  more  apt 
to  have  this  effect  than  a  severer  injury,  which  causes  a 
local  reaction  unfavorable  to  the  growth  of  the  bacilli. 
In  many  cases  of  joint  tuberculosis  all  history  of  trauma 
is  absent;  but  the  disease  often  follows  measles,  whoop- 
ing cough,  and  other  acute  infectious  diseases. 

Symptoms. — The  invasion  is  usually  insidious,  and  the 
symptoms  for  several  months  may  be  obscure  and  inter- 
mittent ;  pain  may  be  absent  in  the  beginning,  and  occa- 
sionally through  the  course  of  the  disease.  The  most 
important  symptoms  are  the  characteristic  postures,  and 
disabilities,  reflex  spasm  of  the  muscles  controlling  the 
affected  joint,  the  rounded  fusiform  swellings  without 
acute  symptoms,  in  superficial  joints,  and  the  tendency  to 
the  formation  of  ichor  pockets  ^  (cold  abscesses).  There 
is  practically  no  fever,  unless  secondary  pus  infection  has 
taken  place. 

The  DIAGNOSIS  can  usually  be  made  from  the  symptoms 
and  course  of  the  affection ;  in  doubtful  cases  the  chances 
are  in  favor  of  tuberculosis  on  account  of  its  frequency, 
especially  in  children.    It  is  important  to  distinguish  pus 

1  Term  proposed  by  the  writer  for  the  collections  of  serum  and  debris  so 
common  in  connection  with  tuberculous  bones  and  joints,  and  which  are  to  be 
sharply  distinguished  from  true  suppuration. 


40  CAUSATION 

and  other  infections,  infantile  scurvy,  hemorrhagic  joints, 
syphilis,  injuries,  and  that  large  and  vague  category 
often  denominated  "  rheumatic,"  or  "  rheumatoid."  In 
spite  of  the  fact  that  rheumatism  is  almost  unknown 
in  infancy,  and  rare  in  early  childhood,  the  commonest 
error  is  to  consider  a  tuberculous  joint  rheumatic.  The 
results  of  such  mistakes  are  often  disastrous.  Skiag- 
raphy, the  tuberculin  test,  and  aspiration  may  aid  in 
diagnosis. 

Tuberculin  in  Diagnosis  (Ogilvy). — Injections  of  tu- 
berculin for  diagnostic  purposes  have  been  employed 
during  the  past  eighteen  years.  A  hypodermatic  injec- 
tion of  five  tenths  of  a  milligram  of  Koch's  old  tuber- 
culin was  usually  given.  An  elevation  of  from  one  to 
three  degrees  of  temperature,  accompanied  by  a  general 
feeling  of  malaise,  indicates  a  positive  reaction. 

Of  Koch's  new  tuberculin  (T.  R.),  one  tenth  of  a  mil- 
ligram is  a  sufficiently  large  dose.  This  preparation, 
with  the  smaller  dosage,  has  eliminated  some  of  the  ob- 
jectionable results  previously  experienced.  The  advan- 
tage of  this  method  is  that  in  localized  tuberculosis  we 
have  a  perceptible  reaction  in  the  area  of  disease.  The 
reaction  is  at  its  height  in  from  twelve  to  fourteen  hours, 
and  passes  away  in  about  twenty-four  hours. 

Vaccination  Test. — ^Von  Pirquet's  method  consists  in 
scarifying  the  skin  through  a  drop  of  Koch's  old  tuber- 
culin. Two  small  areas  about  three  inches  apart  are  so 
vaccinated.  The  skin  between  these  two  areas  is  simply 
scarified ;  no  dressing  need  be  applied.  The  reaction  be- 
gins in  from  ten  to  fifteen  hours,  and  lasts  a  week  or 
more.     The  faintest  reaction  is  easily  detected  by  com- 


INFECTIONS    OF    BONES    AND    JOINTS      41 

parison  with  the  control  spot.  Von  Pirquet  especially 
recommends  this  method  for  young  children. 

The  Eye  Test. — The  Calmette  ophthalmo-tuberculin 
reaction  has,  with  Von  Pirquet's  method,  attracted  much 
attention  during  the  past  year.  One  minim  of  the  1  to 
100  sterile,  saline  solution  of  the  alcoholic  precipitate 
of  Koch's  old  tuberculin  is  dropped  into  one  eye.  At  the 
end  of  three  to  four  hours  a  mild  conjunctivitis  is  noticed. 
The  reaction  continues,  and  becomes  gradually  more  in- 
tense, in  some  instances  resulting  in  a  purulent  conjunc- 
tivitis, with  a  slight  burning  sensation, 

The  reaction  reaches  its  most  acute  stage  in  about 
eighteen  hours  and  passes  off  in  twenty-four  hours.  Oc- 
casionally a  mild  conjunctivitis  may  remain  for  several 
days.  This  method  should  not  be  used  when  an  inflam- 
matory affection  of  the  eye  is  present. 

The  Inunction  Method. — Moro  recommends  rubbing 
into  the  skin  of  the  chest  or  abdomen  an  ointment  of 
Koch's  old  tuberculin,  5  c.c,  with  anhydrous  wool  fat, 
5  grams. 

A  piece  about  the  size  of  a  pea  is  rubbed  into  the 
skin  for  half  a  minute,  over  an  area  of  about  the  size 
of  the  palm  of  the  hand.  In  from  twenty-four  to  forty- 
eight  hours  small  papules  appear,  which  usually  van- 
ish at  the  end  of  a  week.  No  harmful  reactions  have 
followed  this  method.  There  are  apparent  errors  both 
positive  and  negative  in  all  these  reactions. 

The  PROGNOSIS  in  tuberculous  joint  affections  in  chil- 
dren is  distinctly  good  under  rational  treatment;  the 
large  majority  recover  with  useful  limbs. 

The  untreated  and  improperly  treated  cases,  however, 

5 


42  CAUSATION 

either  go  from  bad  to  worse,  and  finally  die  of  acute 
tuberculosis,  tuberculous  meningitis,  sepsis,  waxy  viscera 
(Fig.  17),  exhaustion,  or  intercurrent  diseases,  or  recover 
with  crippling  deformities   and  impaired   constitutions. 


Fig.  17. — Pott's  Disease  Five  Years,  and  Left  Hip  Tuberculosis,  Four 
Years'  Duration;  Multiple  Sinuses;  Deformity;  Waxy  Viscera; 
Boy  of  Eleven. 

As  recovery  takes  place  by  walling  off  infected  foci  and 
cicatrization,  these  patients  are  liable  to  relapse  after 
injury,  though  such  relapses  are  not  common  when  the 
general  condition  is  good.  In  adults  there  is  a  greater 
tendency  to  visceral,  and  particularly  pulmonary  in- 
volvement, and  while  the  prognosis  is  still  good  imder 
good  management,  radical  operations  are  much  oftener 
indicated,  and  the  percentage  of  recoveries  is  smaller 
than  in  children. 

Treatment. — The  two  great  indications  in  joint  tu- 
berculosis are  to  provide  continuous  rest  and  protection 
for  the  diseased  joint  and  to  improve  the  local  and  gen- 
eral nutrition.     Proper  treatment  will  also  include  the 


INFECTIONS    OF    BONES    AND    JOINTS      43 

prevention  and  correction  of  deformity.  Under  such 
management  tlie  large  majority  recover  with  fair  health 
and  good  locomotion. 

It  was  recognized  by  the  American  pioneers  in  ortho- 
pedic surgery  that  confinement  to  bed  for  long  periods  is 
unhygienic,  and  it  is  their  great  merit  to  have  devised 
effective  means  of  splinting  and  protecting  the  joints, 
while  still  allowing  locomotion,  at  least  during  the  long 
stage  of  convalescence,  and  permitting  the  patient  to  live 
in  the  fresh  air,  recognized  then  as  now  as  our  most  pow- 
erful tonic.  To  neglect  either  side  of  the  problem  is  a 
grave  error;  if  by  fats,  milk,  eggs,  and  a  nutritious  and 
generous  diet,  fresh-air  life,  attention  to  elimination  and 
other  means,  we  can  improve  the  general  condition,  the 
richer  blood  will  surely  improve  local  nutrition.  This 
will  hardly  be  possible  in  the  active  stages  of  the  disease, 
unless  suffering  is  relieved,  and  joint  damage  prevented 
for  a  long  period  by  mechanical  means.  For  both  general 
and  local  reasons,  the  patient's  activity  should  be  much 
curtailed,  the  hours  of  rest  prolonged,  and  periods  of  re- 
cumbency enforced  when  indicated. 

When  the  tuberculous  focus  is  extra-articular  and 
accessible,  it  should  be  removed  by  a  surgical  operation. 
In  desperate  cases,  the  result  of  neglect,  or  in  those  where 
the  tonic  and  rest  treatment  has  failed,  as  sometimes  oc- 
curs, erasions  and  excisions  may  be  required.  Early 
excisions  in  children  have  been  extensively  tried  and 
abandoned  as  unsatisfactory,  but  are  occasionally  de- 
manded  as  a  life-saving  measure.  The  immediate  and 
remote  mortality  is  nearly  one  half,  which  may  be  bet- 
ter than  the  natural  mortality  in  these  desperate  cases. 


44  CAUSATION 

In  adults  excision  of  a  tuberculous  joint  gives  excellent 
results,  and  is  often  the  treatment  of  choice. 

DISEASES  OF  UNKNOWN  ORIGIN 

"  Rheumatoid "  affections  form  a  very  important  and 
very  difficult  division  of  joint  troubles,  in  which  consid- 
erable interest  has  been  aroused  by  the  labors  of  Gold- 
thwait  and  his  associates  in  this  country,  and  by  other 
investigators.  It  is  doubtful  if  there  is  any  disease 
properly  designated  as  chronic  rheumatism;  the  affec- 
tions heretofore  so  called,  which  may  be  monarticular 
or  polyarticular,  are  divisible  into 

1.  Villous  aetheitis,  characterized  by  hypertrophy 
of  the  synovial  membrane  and  its  fringes. 

2.  Infectious  aetheitis,  as  already  described;  infec- 
tions from  various  specific  microbes  and  toxins. 

3.  Aetheitis  defoemans,  characterized  by  atrophy 
and  stiffness,  which  may  begin  acutely  with  effusion  and 
constitutional  symptoms,  but  often  becomes  extremely 
chronic,  and  may  result  in  much  deformity,  stiffness,  and 
disability. 

Villous  aetheitis  is  characterized  by  thickening  of 
the  synovial  membrane  and  hypertrophy  of  the  synovial 
villi.  It  may  be  primary,  or  secondary  to  various  joint 
infections  and  to  arthritis  deformans.  The  joint  may 
contain  masses  of  soft  tabs,  or  wormlike  villi,  which  may 
cause  enlargement  and  may  sometimes  be  palpated.  The 
hypertrophied  villi  may  undergo  fatty  degeneration  and 
change  to  a  joint  lipoma  (lipoma  arborescens).  The 
rubbing  of  these  masses  when  the  joint  is  moved  often 
causes  more  or  less  creaking  and  snapping.     The  knee 


DISEASES   of;  unknown    origin  45 

is  the  joint  most  commonly  affected.  If  the  masses  are 
pinched  in  the  movements  of  the  joint  a  local  synovitis 
with  pain,  swelling,  tenderness,  and  disability  may  re- 
sult; these  symptoms  sometimes  resemble  those  of  a 
floating  body,  or  semilunar  injury.  Creaking  is  often 
present  without  other  symptoms,  and  it  is  probable  that 
hypertrophied  villi  of  moderate  extent  often  cause  no 
disability. 

Cases  with  pain,  swelling,  and  moderate  disability 
are  often  relieved  by  strapping,  bandaging  (or  knee- 
cap), and  the  vibrator  or  high-tension  current.  Intract- 
able cases  may  require  excision  of  the  villi. 

Akthkitis  deformans  is  characterized  by  atrophy  of 
bone  and  soft  parts,  wearing  away  of  cartilage,  deform- 
ity, pain,  and  stiffness.  In  the  early  stage  there  is 
joint  effusion  and  swelling.  It  usually  affects  a  great 
many  joints,  beginning  with  the  proximal  interphalan- 
geal  joints;  there  is  a  tendency  to  bilateral  symmetry. 
It  frequently  begins  in  young  adults,  and  a  juvenile  form 
has  been  described.  In  the  form  called  osteoaethritis, 
in  addition  to  atrophy  of  the  pressure-bearing  structures, 
there  are  bony  outgrowths  at  the  margins  of  the  joints 
(Fig.  18),  and  in  some  instances,  especially  in  the  spine, 
there  is  ossification  of  ligaments.  This  form  does  not 
usually  affect  so  many  joints,  and  may  be  monarticular. 
It  does  not  so  often  affect  the  finger  joints,  and  when  it 
does  it  usually  affects  the  terminal  joints  first.  It  may 
affect  a  single  joint  after  an  injury  or  after  repeated  in- 
sults (great  toe  joint).  The  process  may  sometimes  be 
arrested  before  causing  serious  damage.  Senile  changes 
may  take  place,  particularly  at  the  hip,  knee,  or  shoulder, 


46  CAUSATION 

which  result  in  a  wearing  away  of  the  joint  surfaces,  with 
the  production  of  osteophytes  about  the  periphery,  caus- 
ing pains,  deformity,  and  stiffness.  It  is  doubtful 
whether  these   cases   should  be   classed   with   ordinary 


Fig.  18. — Osteoarthritis  of  Knee  Showing  Osteophytes.  Osteoar- 
thritis OF  Hip  Showing  Deformation  and  Dislocation  op  the  Head 
OF  the  Femur.  (Specimens  from  College  of  Physicians  and  Surgeons, 
New  York.) 

osteoarthritis.  The  cause  of  arthritis  deformans  with  or 
without  osteophytes  is  unknown,  though  it  may  be  infec- 
tion or  autointoxication  from  intestinal  indigestion  in 
certain  cases.  Acute  rheumatism,  excluding  the  acute 
stage  of  arthritis  deformans,  and  the  specific  joint  infec- 
tions, is  rarely  followed  by  permanent  stiffness.    Eecent 


DISEASES   OF    UNKNOWN    ORIGIN  47 

investigations  render  it  probable  that  acute  rheumatism 
is  also  due  to  microbic  infection,  whether  specific  or  not 
is  still  uncertain. 

Arthritis  deformans  in  the  chronic  stage  demands 
tonic  treatment,  measures  directed  to  improve  the  diges- 
tion (hydrochloric  acid),  and  elimination,  a  nourishing 
diet  which  shall  not  exclude  meat,  and  may  often  with 
advantage  include  fats  and  sterilized  milk  soured  by 
lactic  acid  bacteria ;  and  other  measures  to  promote  gen- 
eral and  local  nutrition,  like  vibration,  oil  inunctions,  the 
high  frequency  current,  electric  light,  hot  air  and  sun 
baths,  hot  and  cold  douches,  hot  saline  compresses,  wrap- 
ping the  joints  with  rubber  tissue,  and  graduated  move- 
ments. Antirheumatic  treatment,  such  as  the  iodides, 
the  alkalies,  the  salicylates,  strenuous  bathing,  and  a 
low  diet,  are  usually  harmful,  and  should  be  avoided. 

In  the  active  stage  the  patient  should  be  kept  quiet 
and  the  joints  should  be  supported  by  splints,  as  in  other 
joint  inflammations.  The  relief  given  by  such  measures 
is  often  surprising.  After  subsidence  of  the  acute  symp- 
toms, deformities  may  be  overcome  by  stretching  or  the 
use  of  moderate  force  under  anesthesia,  care  being  taken 
not  to  attempt  too  much  at  one  time,  which  usually  does 
harm,  and  to  retain  the  correction  gained,  by  retentive 
splints.  Protective  splints  are  also  sometimes  of  great 
utility. 

Still's  disease  is  a  chronic  polyarthritis  of  childhood, 
with  enlargement  of  the  liver,  spleen,  and  glands,  fever, 
and  constitutional  symptoms.  Most  of  the  joints  become 
involved,  and  the  child  is  cachectic  and  helpless  (Figs. 
19  and  20).     The  symptoms  resemble  those  of  an  in- 


48 


CAUSATION 


fective  process;  there  is  considerable  natural  tendency 
to  a  recovery  more  or  less  complete.  A  similar  polyar- 
thritis occurs  in  children  without  notable  visceral  or 
glandular  enlargement. 


Fig.   19.— Polyarthritis   in   Girl  Aged 
Six;  Active  Stage.     (Townsend's  case.) 


Fig.  20. — -Polyarthritis 
(Still's  Form),  in  Boy 
OF  Five.  Began  at  one 
year  of  age ;  now  conva^ 
lescent  under  thymus 
extract. 


In  several  recent  cases  re- 
markable improvement  occurred 
after  the  administration  of  5  to 

20   grains   of   dried   thymus   gland   three   times   a   day 
(Nathan). 

Toxic  Osteoperiostitis  {secondary  hyperplastic  ostitis; 
osteoarthropathie  hypertrophiante  pneumonique) . — This 
is  a  disease  characterized  by  congestion  and  clubbing  of 


DISEASES    OF    UNKNOWN    ORIGIN  49 

the  fingers  and  toes,  and  enlargement  of  the  phalanges 
from  deposit  of  bone.  It  is  always  secondary  to  chronic 
visceral  disease,  usually  of  the  lungs.  It  is  sometimes 
found  in  children  in  connection  with  Pott's  disease  of  the 
spine,  when  complicated  with  chronic  lung  disease  (Fig. 
21).  In  mild  cases  the  digits  alone,  particularly  the  ter- 
minal phalanges,  are  involved ;  in  more  severe  cases  the 
forearm  and  leg  bones  are  also  affected.  A  few  cases  are 
so  severe  as  to  be  distorting  to  the  hands  and  feet  and  to 


Fig.  21. — Toxic  Osteoperiostitis  in  a  Boy  op  Ten  with  Pott's  Disease. 

(Nathan.). 

cause  marked  hypertrophy  of  the  bones  of  the  extrem- 
ities ;  it  is  then  sometimes  confounded  with  acromegaly, 
but  lacks  the  hypertrophy  of  the  face.  The  disease  is 
uncommon  and  unimportant  from  an  orthopedic  stand- 
point. 


50  CAUSATION 

Acromegaly  is  characterized  by  great  enlargement  of 
the  hands,  feet,  and  face ;  bones  and  soft  tissues  are  hy- 
pertro23hied.  Certain  cases,  especially  those  starting  in 
childhood,  are  associated  with  gigantism.  Round  back 
and  lateral  curvature  occur.  The  disease  is  of  slow  de- 
velopment and  course,  occurs  in  adult  life,  and  treatment 
is  unavailing.  It  is  thought  to  be  due  to  disease  of  the 
pituitary  gland. 

Recently  Hochenegg,  of  Vienna,  reports  a  case  of 
acromegaly  of  five  years'  duration  in  a  patient  aged 
tliirty,  in  which  he  removed  an  adenoma  of  the  hy- 
pophysis by  the  nasal  route.  The  symptoms  were  alle- 
viated within  a  few  days,  and  the  hands,  feet,  and  jaws 
became  smaller. 

According  to  Hutchinson,  acromegaly  and  gigantism 
are  the  same  disease,  occurring  in  adult  life  and  child- 
hood respectively. 

Ostitis  deformans  {Paget's  disease  of  the  bones)  is  a 
disease  of  the  long  bones  and  skull,  where  regressive 
changes  are  accompanied  by  bone  hypertrophy.  The 
skull  becomes  large  and  thick,  and  the  long  bones  in- 
crease in  diameter  and  length;  the  femora  and  tibise 
often  become  bowed,  and  the  back  becomes  rounded  and 
sometimes  scoliotic  (Figs.  22  and  23).  The  disease  may 
be  restricted  to  a  few  bones  (Fig.  181) ;  it  does  not 
affect  the  face,  digits,  or  joints.  It  is  a  disease  of 
advanced  life;  the  cause  is  unknown,  and  treatment 
unsatisfactory. 

Hyperostosis  of  the  skull  (leontiasis  ossea)  is  a  rare 
disease,  characterized  by  enormous  enlargement  of  the 
bones  of  the  skull  and  face,  sometimes  in  the  form  of 


DISEASES   OF   UNKNOWN    ORIGIN 


51 


tumors.     It  is  chronic  in  its  course,   and  of  unknown 
causation. 


Fig.  22.  Fig.  23. 

Figs.  22  and  23. — Ostitis  Deformans  (Facet's  Disease);  Generalized 

Form. 


In  ostitis  fibrosa  the  medulla  of  certain  bones  becomes 
in  part  replaced  by  fibrous  tissue,  with  atrophy  of  sur- 


52 


CAUSATION 


rounding  bone;  the  process  is  often  painless.  Cysts  are 
sometimes  formed  from  softening  of  the  new  tissue,  and 
may  lead  to  spontaneous  fracture.     This  is  a  rare  con- 


FiG.  24. — Osteomalacia  in  a  Girl  of  Nine,  Who  Since  Age  of  Five  has 
HAD  Repeated  Fractures  of  Upper  Ends  of  Both  Femora.  (Hos- 
pital for  the  Ruptured  and  Crippled.) 


TUMOES    OF    CARTILAGE   AND   BONE       53 

dition,  but  may  occur  in  children  and  adolescents;  it  is 
very  insidious.  When  it  is  discovered  by  the  X-ray  or 
after  spontaneous  fracture,  the  diseased  tissue  should  be 
excised  by  an  operation.  In  such  cases  the  prognosis  is 
good,  as  a  radical  cure  nearly  always  results.  It  is  prob- 
able that  some  of  the  cases  of  juvenile  osteomalacia  be- 
long under  this  head. 

Osteomalacia  is  a  bone  degeneration  where  the  lime 
salts  are  absorbed  and  the  bone  rendered  brittle  or  soft ; 
it  may  affect  most  of  the  bones  of  the  body.  The  puer- 
peral form  seems  to  be  more  common  in  Europe,  but  the 
disease  may  occur  in  men  and  in  children ;  there  is  also  a 
senile  form.  Spontaneous  fractures  often  occur,  fre- 
quently followed  by  deformation  (Fig.  24).  In  puer- 
peral cases  good  results  have  followed  the  removal  of 
the  ovaries.  In  men  and  children,  measures  directed  to 
improve  nutrition  are  the  main  reliance. 

Bossi  believes  the  fault  to  lie  in  deficiency  of  supra- 
renal secretion,  and  reports  good  results  from  the  admin- 
istration of  suprarenal  extract. 

BENIGN  TUMORS  OF  CARTILAGE  AND  BONE 

Chondromata  may  occur  as  single  tumors  on  or  in  any 
part  of  a  bone,  but  are  oftenest  found  near  the  extrem- 
ities, especially  the  fingers ;  they  are  often  multiple,  and 
may  be  more  or  less  ossified — osteochondromata. 

Multiple  osteochondromata  are  often  an  inherited 
family  disease;  their  most  frequent  seat  is  near  the  ends 
of  the  shafts  of  large  bones.  They  are  benign  in  char- 
acter, but  tend  to  recur  after  removal,  and  often  cause 
deformity  and  disability  by  their  number  and  size  and  by 


54 


CAUSATION 


interfering  with  the  growth  of  the  bone  to  which  they  are 
attached.  They  occasionally  spontaneously  diminish  in 
size. 

Osteoma  is  a  benign  bone  tumor,  which  may  be  devel- 
oped from  cartilage  or  fibrous  tissue,  and  may  be  at- 
tached to  bone  or  de- 
veloi3ed  in  other  tissues 
(Fig.  25).  When  they 
become  troublesome 
from  their  size  or  from 
interfering  with  func- 
tion, they  require  re- 
moval. 

Myositis  Ossificans. — 
In  the  progressive  form 
of  this  disease  bone  is 
deposited  first  in  the 
trapezii  or  other  back 
muscles ;  later  many 
other  muscles  are  suc- 
cessively involved, 
causing  stiffness  of  the 
joints  which  they  con- 
trol (Fig.  26).  Oper- 
ative or  other  treat- 
ment is  of  little  value. 
There  are  two  trau- 
matic forms,  of  which 
the  first  is  caused  by  repeated  slight  local  injuries; 
such  are  dancers'  bone  in  the  calf,  riders'  bone 
in    the    thigh    adductors,    fencers'    bone    in    the    bra- 


FiG.  25.  —  Benign  Exostosis  Lower 
End  of  Tibia  and  Fibula.  (Hospi- 
tal for  the  Ruptured  and  Crippled.) 


TUMORS    OF    CARTILAGE    AND    BONE       55 


chialis  anticus,  and  gunners'  bone  in  the  pectoralis 
major.  This  form  has  no  tendency  to  spread  beyond 
the  affected  muscle. 
A  second  traumatic 
form  may  be  excited 
by  a  single  sprain, 
bruise,  or  dislocation, 
particularly  where 
the  periosteum  is  in- 
jured (Fig.  27).  This 
form  may  occur  in 
children  or  adults;  in 
Germany  it  is  par- 
ticularly common  in 
recruits  in  the  early 
twenties.  Bone  may 
be  deposited  within  a 
month  or  two  at  the 
site  of  the  injury, 
not  always  in  mus- 
cle, and  may  be  free 
or  attached.  The 
commonest  site  is  on 
the  upper  arm  and 
thigh,  particularly  the 
brachialis  anticus, 
biceps  brachii,  quad- 
riceps, and  thigh 
adductors.  The  X-ray  is  required  for  exact  diagnosis. 
If  there  is  serious  stiffness  of  the  corresponding  joint, 
the   growth    should   be   removed.      Passive   movements 


Fig.  26. —  Myositis  Ossificans,  Diffuse 
Form.  (Royal  College  of  Surgeons, 
London.     Phelps.) 


56 


CAUSATION 


Fig.  27. — Myositis  Ossificans,  Local  Form;  Man  of  Forty-five.  Blow 
on  calf  fifteen  years  before,  followed  by  slowly  progressing  stiffness  at 
ankle.     (Hospital  for  the  Ruptured  and  Crippled.) 

should  be   delayed   to   avoid   recurrence,   wliich  is   not 
infrequent. 

Bone  Cysts. — Solitary  bone  cysts  usually  occur  near  the 
end  of  the  diaphysis  of  the  long  bones,  especially  at  the 


TUMORS    OF    CARTILAGE    AND    BONE       57 

upper  end  of  the  femur.  They  are  found  most  frequently 
in  children,  adolescents,  or  young  adults,  and  may  cause 
pain,  tenderness,  lameness,  and  expansion  of  bone,  and 
sometimes  lead  to  spontaneous  fracture  (Figs.  28  and 
29).    They  are  usually  revealed  by  the  X-ray,  or  during 


Fig.  28. — Benign  Cyst  Lower  End  of  Tibia;  Symptoms  Two  Months; 
Extirpation;  Recovery.  Boy  of  Nine.  Probably  a  case  of  ostitis 
fibrosa. 

the  course  of  an  operation,  and  are  benign  and  curable, 
if  completely  extirpated.  They  sometimes  heal  after 
simple  puncture.  There  has  been  considerable  discussion 
as  to  the  pathogenesis  of  these  cysts.  The  best  opinion 
seems  to  be  that  they  arise  from  the  softening  of  enchon- 
dromata  and  giant-celled  sarcomata,  fragments  of  which 
have  sometimes  been  found  in  the  cyst  walls.    They  may 

6 


58 


CAUSATION 


also  arise  from  inflammatory  processes,  such  as  rare- 
fying ostitis,  or  ostitis  and  osteomyelitis  fibrosa.  The 
latter  are  sometimes  multiple,  and  may  involve  nearly 


Fig.  29. — Benign  Cyst  op  Neck  of  Femur  in  a  Youth  of  Eighteen; 
Symptoms  One  and  a  Half  Years;  Extirpation;  Recovery. 


the  whole  of  the  shaft  of  the  bone.  Multiple  bone  cysts 
are,  however,  rare.  They  may  result  from  the  soften- 
ing of  new  growths,  and  also  occur  in  certain  cases  of 


MALIGNANT    DISEASES    OF    THE    BONES     59 

osteomalacia,  ostitis  deformans,  and  arthritis  deformans. 
Normal  bone  may  undergo  excessive  expansion  and  me- 
dullization  after  contusion  or  fracture — cal  souffle. 

Bone  tumors  and  cysts  may  also  be  of  parasitic  origin, 
as  the  cysts  and  tumors  of  the  echinococcus,  of  the  cys- 
ticercus,  of  actinomycosis,  and  of  blastomycosis.  Para- 
sitic diseases  of  bone  are  rare  in  this  country. 

MALIGNANT  DISEASES  OF  THE  BONES 

Sarcoma  of  the  long  bones  may  be  central  or  periosteal ; 
the  latter  are  the  more  malignant.  A  history  of  injury  is 
given  in  over  one  third  of  the  cases.  The  growth  usually 
appears  a  few  weeks  after  the  injury,  but  it  is  now  known 
that  in  a  few  cases  the  tumor  follows  directly  upon  the 
injury,  and  increases  with  incredible  rapidity.  The 
favorite  site  is  the  most  rapidly  growing  ends  of  the  long 
bones  of  the  extremities ;  the  lower  end  of  the  femur,  up- 
per end  of  the  tibia,  and  upper  end  of  the  humerus.  The 
periosteal  form,  usually  composed  of  round  or  spindle 
cells,  often  involves  the  middle  third  of  the  shaft  (Fig. 
30),  and  is  more  malignant  than  the  medullary  form, 
which  is  more  often  of  the  giant-celled  variety.  The  dis- 
ease is  one  of  extreme  malignancy;  even  after  early  am- 
putation at  the  proximal  joint  fatal  metastasis  usually 
follows.  Paradoxically,  conservative  operations,  such  as 
excisions  of  the  tumor,  give  somewhat  more  favorable 
statistics  than  amputation,  and  are  strongly  advocated 
by  some  (Borchard).  A  few  inoperable  and  recurrent 
cases  have  been  cured  by  injections  of  the  mixed  toxins 
of  the  erysipelas  and  prodigiosus  bacillus  (Coley). 
"While  some  good  results  have  been  reported  from  the 


60 


CAUSATION 


use  of  the  X-ray,  the  treatment  is  usually  disappointing, 

and  often  harmful.     It  is  very  important  to  distinguish 

between  sarcoma  and 
other  bone  diseases, 
and  the  X-ray  is  here 
very  useful ;  when  the 
diagnosis  is  in  doubt, 
it  is  advisable  to  re- 
move a  piece  of  the 
tumor  by  an  explora- 
tory operation,  and 
have  it  examined  by 
a  pathologist. 

Disseminated  sar- 
comatosis  has  little 
interest  for  the  ortho- 
pedic surgeon. 

Hypernephroma  is  a 
specific  neoplasm  of 
the  suprarenal  bod- 
ies; it  sometimes  in- 
volves one  or  more 
of  the  long  bones  sec- 
ondarily. This  sec- 
ondary bone  disease 
may  be  the  first  thing 
to  attract  attention, 
and  may  be  the  only 

complication.    The  appearance  and  course  of  the  disease 

is  much  like  that  of  sarcoma. 

When  a  rapidly  growing  solid  bone  tumor  is  found  in 


Fig.  30. — Periosteal  Sarcoma  of  Upper 
End  of  Left  Femur.  (Hospital  for 
the  Ruptured  and  Crippled.)., 


FRACTURES  61 

a  person  past  forty,  the  urine  should  be  examined  for 
blood,  the  kidney  region  for  enlargement,  and  the  scro- 
tum for  varicocele  of  sudden  onset. 

Carcinoma. — In  general  carcinomatosis  of  the  bones, 
the  latter  may  become  soft  and  bend  or  break.  This  con- 
dition has  sometimes  been  mistaken  for  osteomalacia,  and 
has  received  the  misleading  name  of  osteomalacia  car- 
cinomatosa.  This  disease  is  secondary,  and  may  last 
many  years. 

Local  carcinoma  of  bone  is  also  nearly  always  sec- 
ondary; it  occurs  frequently  with  cancer  of  the  thyroid, 
breast,  pancreas,  and  prostate.  Carcinoma  of  the  spine 
occasionally  develops  after  carcinoma  of  the  pancreas, 
breast,  and  other  viscera.  It  is  extremely  painful,  and 
if  the  tumor  presses  upon  the  cord,  it  is  complicated  by  a 
paraplegia  which  has  received  the  name  of  paraplegia 
dolorosa.  This  should  not  be  confounded  with  ordinary 
pressure  paraplegia  from  Pott's  disease,  which  is  usually 
curable.     Carcinoma  of  the  bones  is  incurable. 

Multiple  myeloma  is  a  term  used  for  numerous  small 
tumors  of  the  medullary  cavity  of  varying  pathology,  but 
usually  malignant.  There  is  pain  and  tenderness  of  the 
bone  at  times,  and  sometimes  bone  softening,  but  the  bone 
symptoms  are  usually  obscure,  and  frequently  unnoticed. 
In  many  of  these  cases  Bence  Jones's  albumose  is  found 
in  the  urine.  The  prognosis  is  unfavorable,  and  the  treat- 
ment unsatisfactory. 

FRACTURES 

Spontaneous  fracture  may  occur  in  tumors  and  cysts  of 
the  long  bones,  in  rickets,  in  gmnmata,  in  tuberculous 


62  CAUSATION 

or  osteomyelitic  diseases  of  the  shaft,  or  of  the  neck  of 
the  femur;  in  parasitic  bone  diseases;  in  neglected  cases 
of  scurvy;  in  ostitis  fibrosa,  and  in  fragilitas  ossium, 
and  osteomalacia. 

TTnunited  fracture  occurs  occasionally  after  cuneiform 
osteotomy,  rarely,  if  ever,  after  linear  osteotomy.  It 
may  occur  from  imperfect  apposition  or  retention,  after 
infected  fractures,  or  from  some  defect  in  nutrition.  The 
writer  has  seen  a  case  of  ununited  fracture  of  both  bones 
of  the  forearm,  which  had  never  been  well  splinted,  unite 
in  a  couple  of  months  after  the  forearm  had  been  immo- 
bilized in  a  well-fitting  splint.  In  the  lower  extremity, 
if  the  bone  is  held  in  good  coaptation  by  a  proper  appa- 
ratus, the  irritation  of  weight-bearing  in  walking  will 
sometimes  effect  union.  Cases  of  cure  after  the  admin- 
istration of  extract  of  thyroid  gland  have  been  reported, 
also  after  the  injection  of  blood  (Bier),  and  of  irritating 
fluids,  such  as  tincture  of  iodin,  or  in  the  introduction  of 
decalcified  bone  splinters  about  the  site  of  the  fracture 
(Phelps).  One  should  not  be  too  ready  to  cut  down  on 
the  fragments  and  wire  or  suture  them,  as  has  been 
largely  recommended  and  practiced.  The  results  are 
often  disappointing.  The  method  of  uniting  the  frag- 
ments by  introducing  small  aluminium  cylinders  into  the 
medullary  cavity  (Elsberg)  is  very  joromising.  In  old 
ununited  fracture  of  the  neck  of  the  femur  the  fragments 
should  be  exposed,  freshened,  replaced,  and  united  in 
forced  abduction  by  a  steel  drill,  or  by  sutures  of  silk  or 
chromicized  gut  introduced  through  the  periosteum. 

The  osteoplastic  operation  of  Miiller  of  Eostock 
is  exceedingly  clever,  and  should  give  good  results  in 


NERVOUS   AFFECTIONS  63 

proper  cases.  A  long,  tongue-shaped  skin  flap,  with  its 
base  on  the  proximal,  its  apex  on  the  distal  fragment,  is 
cut  down  to  the  periosteum.  From  its  apex  a  thin  layer 
of  bone  is  chiseled  off  to  the  point  of  fracture;  it  lies 
under  and  is  attached  to  the  flap.  From  the  fracture  to 
the  base  of  the  flap  the  periosteum  with  the  flap  is  sepa- 
rated from  the  bone,  so  that  the  skin  flap  carries  peri- 
osteum at  its  base,  periosteum  and  bone  at  its  apex.  The 
flap  is  raised,  the  fracture  laid  bare  and  refreshed,  and 
interposed  tissue  removed,  and  the  fragments  placed  in 
correct  apposition.  The  flap  is  then  drawn  upward  by 
wrinkling  the  base,  so  that  the  bone  periosteum  flap  comes 
to  lie  over  the  point  of  fracture,  overlapping  both  frag- 
ments.   The  parts  are  then  sutured  and  immobilized. 

NERVOUS  AFFECTIONS 

Peripheral,  spinal,  and  cerebral  lesions  of  the  nervous  sys- 
tem are  a  prolific  cause  of  deformation  and  disability. 
Brachial-plexus  palsy  from  rupture  of  one  or  more  cords 
of  the  brachial  plexus  at  birth,  crutch  palsy,  and  the  drop- 
wrist  of  musculo-spiral  and  lead  palsy  are  examples  of 
crippling  affections  due  to  peripheral  lesions.  The  re- 
sulting palsy  is  flaccid,  and  associated  with  rapid  degen- 
eration of  the  nerve  peripheral  to  the  lesion  and  to 
wasting  of  the  connected  muscles,  and  slower  wasting  of 
the  limb ;  reflexes  in  the  affected  area  are  absent.  If  the 
injury  is  due  to  pressure,  as  in  crutch  and  musculo-spiral 
palsy,  recovery  may  be  looked  for  on  removal  of  the  pres- 
sure. In  using  crutches,  if  the  weight  be  largely  borne 
on  the  hands,  instead  of  on  the  axillae,  the  danger  of 
crutch  palsy  is  avoided.     If  a  nerve  is  torn  or  cut,  it 


64  CAUSATION 

usually  unites,  with  regeneration  and  restoration  of  func- 
tion, after  nerve  suture  with  excision  of  cicatricial  tissue, 
and  this  is  possible  many  years  after  the  injury.  In  the 
management  of  the  palsy,  the  paralyzed  muscles  should 
be  protected  from  stretching  and  strain  by  being  con- 
stantly supported  in  the  relaxed  (shortened)  posture. 
For  instance,  in  drop-wrist,  the  hand  should  be  supported 
by  a  splint  in  hyperextension  (Thomas) ;  in  facial  palsy, 
the  corner  of  the  mouth  should  be  hooked  up.  Such  man- 
agement favors  the  nutrition  of  the  aifected  muscles,  and 
prevents  subsequent  deformity. 

In  partial  paralysis  the  weakened  part  should  be  used 
so  far  as  possible,  after  the  first  few  weeks,  in  the  or- 
dinary activities  of  life,  and  movements  should  be  prac- 
ticed to  increase  motion  in  the  directions  in  which  it  is 
limited,  and  to  develop  weakened  muscles.  Most  author- 
ities lay  great  stress  on  the  use  of  massage  and  electricity 
to  promote  local  nutrition,  but  protection  and  use,  with  a 
few  simple  manipulations  to  facilitate  joint  motion,  are 
much  more  important.  The  use  of  the  vibrator  in  recov- 
ering palsies  is  often  beneficial.  Fixed  deformities  re- 
quire special  treatment,  which  will  be  described  in  the 
special  part. 

Cerebral  palsies  may  arise  from  defective  development 
of  the  motor  tracts,  often  associated  with  premature 
birth,  from  hydrocephalus,  head  injuries  at  birth,  and 
cerebral  lesions  in  infancy  and  childhood.  Cerebration 
is  usually  more  or  less  impaired,  and  such  palsies  are 
common  in  idiots  and  imbeciles ;  convulsions  occur  in  a 
considerable  proportion.  This  is  a  somewhat  hetero- 
geneous group  pathologically,  but  it  is  characterized  clin- 


NERVOUS   AFFECTIONS  65 

ically  by  incoordination,  rigidity,  or  spasticity  of  the 
muscles  and  increased  reflexes  in  the  affected  area.  True 
atrophy  is  absent,  though  growth  may  be  retarded.  The 
palsy  may  be  a  hemiplegia,  paraplegia,  or  diplegia.  If 
the  affection  is  congenital  or  occurs  before  the  child  has 
walked,  locomotion  may  be  much  delayed,  though  most  of 
the  cases  not  complicated  by  idiocy  or  hydrocephalus  do 
finally  walk,  sometimes  as  late  as  the  sixth  or  seventh 
year.  There  is  a  strong  tendency  to  flexion,  adduction, 
and  inversion  of  the  lower  limbs  from  unbalanced  mus- 
cular action,  the  stronger  groups  predominating.  When 
patients  walk,  if  both  sides  are  affected,  the  gait  is  stiff 
and  uncertain,  the  feet  turn  in,  and  the  knees  rub  to- 
gether. These  contractions  may  be  stretched  out  by  the 
hand  or  by  instruments,  but  they  tend  to  recur.  Very 
much  may  be  done  for  these  patients  by  systematic  mind 
and  muscle  training,  through  purposive  muscular  move- 
ments. The  deformities  frequently  require  special  treat- 
ment by  tenotomies,  myectomies,  and  splinting.  Tenot- 
omy of  persistently  shortened  muscles  not  only  corrects 
the  deformity,  but  tends  to  allay  spasm,  and  bring  about 
a  better  muscular  balance.  Care  should  be  taken  not 
to  overcorrect  after  tenotomy  of  the  heel  cord,  as  such 
overcorrection  may  become  permanent. 

Spinal  paralyses  form  a  very  important  group  in  the 
production  of  crippling  affections.  Destruction  of  the 
motor  cells  of  the  cord  in  a  given  area,  as  in  acute  polio- 
myelitis, causes  a  flaccid  palsy  with  descending  nerve  de- 
generation, bone  and  muscle  atrophy,  vasomotor  paresis, 
and  diminished  or  absent  reflexes.  The  symptoms  are 
very  much  like  those  of  peripheral  palsy. 


66  CAUSATION 

Acute  anterior  poliomyelitis  is  a  definite  local  in- 
flammation of  certain  motor  areas,  which  is  followed  by 
degeneration  of  groups  of  motor  cells  in  the  anterior 
cornna.  The  trouble  is  probably  due  to  an  infection;  it 
usually  occurs  in  the  summer,  and  sometimes  in  epi- 
demics, in  healthy  children,  from  six  months  to  five 
years,  though  these  limits  are  often  exceeded.  The 
epidemic  from  June  to  November,  1907,  in  and  around 
New  York  City,  probably  exceeded  two  thousand  cases, 
and  is  the  most  extensive  known.  A  small  percentage 
of  the  cases  were  rapidly  fatal,  but  the  disease  is  not 
ordinarily  dangerous  to  life.  In  a  few  cases  the  paraly- 
sis appears  suddenly  without  constitutional  symptoms. 
Complete  recovery  from  the  paralysis  is  very  rare  even 
in  slight  cases.  The  onset  is  sudden  with  fever,  pros- 
tration, and  sometimes  with  nausea  or  vomiting.  The 
fever  lasts  from  a  few  hours  to  several  days.  While 
the  child  is  in  bed  or  when  it  gets  up,  it  is  found  to  have 
partial  or  complete  paralysis  in  one  or  more  limbs.  There 
may  be  pain  in  the  paralyzed  regions,  which  is  increased 
on  motion.  The  legs  are  much  more  frequently  affected 
than  the  arms;  the  trunk  muscles  are  occasionally  in- 
volved. It  is  common  for  both  legs  to  be  helpless  at  first 
and  for  one  leg  to  make  an  almost  complete,  the  other 
a  partial,  recovery  in  the  first  few  weeks  or  months.  One 
or  both  arms  may  be  paralyzed  with  or  without  paral- 
ysis of  the  legs.  There  is  almost  always  considerable 
tendency  to  spontaneous  recovery  of  power  in  the  first 
six  months ;  none  thereafter.  The  final  result  is  a  palsy 
of  muscle  groups  of  very  irregular  distribution.  There  is 
seldom  symmetrical  palsy^  except  in  the  few  cases  where 


NERVOUS  -AFFECTIONS  67 

a  permanent  paraplegia  is  left;  hemiplegia  is  very  rare. 
As  the  child  lies  in  bed  or  begins  to  sit  up  adaptive 
changes   occur  due  to  habitual  posture   or  unbalanced 


Fig.  31. — Deformities  Following  Poliomyelitis. 
(New  York  City  Children's  Hospital.     Ogilvy's  service.) 


muscular  action,  which  often  cause  permanent  deformi- 
ties of  the  spine,  hip,  knee,  ankle,  and  foot  (Fig.  31). 
These  often  develop  within  a  few  weeks  or  months; 


68 


CAUSATION 


there  is  no  spasm  (Fig.  32).  These  secondary  deformi- 
ties or  the  inability  to  control  one  or  two  major  joints, 
often  prevent  children  from  walking  who  otherwise 
would    be    perfectly   capable    of   doing    so.      Paralysis 


Fig.  32. — Fixed  Drop-foot  (Equinus)  Acquired  within  Eight  Months 

AFTER  AN  ATTACK  OF  POLIOMYELITIS;   PaTIENT  UnABLE  TO   StAND. 


of  the  muscles  controlling  the  feet  and  of  the  quadri- 
ceps are  among  the  commonest  and  also  the  most  im- 
portant disabilities.  The  knee  reflexes  are  diminished 
or  abolished;  atrophy  is  marked  and  the  surface  is  cold 
and  bluish. 

The  diagnosis  is  seldom  made  until  the  paralysis  is 
noticed;  even  then  it  frequently  passes  for  rheumatism, 
and  occasionally  for  joint  disease.  The  mode  of  onset, 
and  sequelae  are  characteristic,  and  if  carefully  studied 


NERVOUS    AFFECTIONS  69 

will  readily  differentiate  this  disorder  from  other  affec- 
tions. 

Treatment. — During  the  attack  and  for  four  to  six 
weeks  thereafter  rest  in  bed  is  of  the  greatest  impor- 
tance, in  order  that  repair  may  go  on  undisturbed.  After 
this  the  prevention  of  the  elongation  of  paralyzed  muscles 
and  of  deformities,  by  appropriate  apparatus,  and  im- 
proving the  circulation  and  nutrition  of  the  limb  are  very 
important.  Nearly  all  deformities  may  be  prevented  by 
careful  splinting  to  relax  and  protect  stretched  muscles. 
Circulation  and  nutrition  are  best  kept  up  by  the  vibra- 
tor and  by  dry  heat  to  the  limb,  and  most  important  of 
all,  by  restoring  the  power  of  locomotion  by  the  appli- 
cation of  apparatus  which  gives  necessary  support. 
Jones  justly  lays  down  the  principles  that  "  a  muscle,  if 
stretched  for  a  sufficiently  long  period,  will  cease  to  act," 
and  "  an  overstretched  muscle  will  regain  its  power  if 
relieved  from  strain,"  and  cites  many  examples.  If  pa- 
tients apply  after  the  development  of  deformities,  these 
should  be  corrected  by  tenotomies  and  stretchings,  and 
the  proper  supporting  braces  applied.  Patients  are  often 
thus  enabled  to  walk,  who  have  never  walked  since  their 
attack  many  years  before.  Arthrodesis  to  stiffen  flail- 
joints  and  tendon  grafting  to  supplement  the  action  of 
weakened  muscles  are  often  valuable,  but  give  the  best 
results  some  years  after  the  attack,  and  usually  after  the 
age  of  eight  or  ten.  The  treatment  of  individual  defor- 
mities is  taken  up  in  the  special  part. 

Another  type  of  spinal  palsy  is  caused  by  a  trans- 
verse lesion  as  in  Pott's  paraplegia.  In  these  cases 
cerebral  inhibition  and  control  is  abolished,  and  reflexes 


70  CAUSATION 

are  exaggerated,  below  the  lesion ;  wasting  is  not  marked. 
If  centers  are  involved  there  will  be  wasting  and  flaccid 
palsy  in  their  distribution.  For  more  details  see  Pott's 
disease. 

Trophic  Joints  {Charcot's  joint). — In  locomotor  ataxia 
and  some  other  cord  diseases,  involving  sensation  and 
nutrition,  a  joint  or  joints  in  the  affected  area  may  be- 
come slowly  and  almost  painlessly  disorganized.  Trophic 
joints  occur  in  about  five  per  cent  of  the  cases  of  loco- 
motor ataxia,  and  their  development  occasionally  pre- 
cedes the  ataxia.  The  knee,  hip,  ankle,  or  lumbar  spine 
may  be  affected.  When  one  of  the  larger  joints  becomes 
chronically  swollen  without  pain  in  a  middle-aged  man, 
the  patient  should  always  be  examined  for  locomotor 
ataxia.  The  affected  bone  becomes  extremely  eroded, 
there  is  a  large  effusion  with  laxity  of  the  ligaments,  and 
finally  a  flail-joint  (Fig.  174).  This  condition  may  be 
palliated  by  a  stiff  splint  giving  antero-posterior  and 
lateral  support.    Excision  has  also  been  proposed. 

Hysteria  is  a  psycho-neurosis  without  demonstrable 
organic  lesion.  Paresis,  deformity,  and  contractures  are 
sometimes  seen  in  the  hysterical,  and  such  affections 
may  be  difficult  to  diagnose  and  to  treat.  Hysterical 
stigmata  will  often  be  found,  or  the  symptoms  may  be 
variable,  or  inconsistent  with  organic  affections.  The 
condition  is  usually  curable  under  appropriate  general 
and  local  management. 


EXAMINATION    AND    DIAGNOSIS  71 

EXAMINATION   AND    DIAGNOSIS   IN 
ORTHOPEDIC    PRACTICE 

Examination. — The  key  to  orthopedic  diagnosis  in  chil- 
dren is  to  remove  the  clothing  and  to  examine  them  all 
over.  More  than  half  of  the  frequent  and  serious  errors 
are  due  to  failure  to  follow  this  simple  plan.  It  will  help 
vastly  if  one  has  a  definite  idea  of  what  is  to  be  looked 
for,  and  the  determination  to  find  an  adequate  cause  for 
the  symptoms.  One  should  note  primarily  disturbances 
of  form  and  function  and  only  secondarily  seek  to  de- 
termine the  pathological  cause.  In  general  terms  the 
examiner  should  look  for  weakness  or  laxity,  stiffness 
or  spasm,  wasting,  swelling,  tenderness  and  deformity 
of  the  trunk  and  limbs,  and  particularly  of  the  joints, 
and  note  their  presence  or  absence.  The  examination 
begins  the  moment  the  patient  enters.  Even  if  the  child 
is  carried,  its  color,  expression,  nutrition,  postures, 
movements,  and  general  demeanor  should  give  valuable 
information,  while  if  the  child  walks,  the  gait,  attitude, 
and  movements  should  be  critically  studied.  The  tipped- 
back  head,  retracted  shoulders,  stiff  back,  and  careful 
movements  of  Pott's  disease,  the  waddling  gait  of  bi- 
lateral congenital  hip  dislocation,  the  weak,  floppy,  or 
dragging  walk  of  poliomyelitis,  the  stiff,  spastic  gait  of 
cerebral  palsy,  and  many  others  are  practically  pathog- 
nomonic. One  may  observe  at  once  whether  lameness 
is  present  on  one  or  both  sides,  and  whether  the  gait  in- 
dicates weakness  or  stiffness,  tenderness,  shortness,  or 
deformity  and  at  which  joint.  All  the  movements  should 
be  carefully   studied  and  deviations   from   the   normal 


72  EXAMINATION    AND    DIAGNOSIS 

noted,  also  whether  handling  and  undressing  the  child 
causes  pain.  While  the  child  is  being  undressed  the 
main  points  of  the  history  are  ascertained,  and  particu- 
larly if  there  was  a  difficult  labor,  if  there  was  any  injury 
or  abnormality  at  birth ;  what  was  the  manner  of  feeding 
and  the  state  of  health  during  infancy ;  whether  the  child 
had  been  injured  or  had  had  one  or  more  attacks  of  ill- 
ness ;  what  had  first  attracted  attention  in  connection  with 
the  present  affection ;  what  had  been  the  symptoms,  their 
duration  and  order  of  development;  whether  they  had 
come  quickly  or  slowly  and  with  or  without  constitu- 
tional reaction.  The  child,  being  now  completely  un- 
dressed, is  asked  to  walk,  to  lie  down  and  get  up,  and 
to  pick  up  some  small  object.  It  is  then  examined  stand- 
ing for  spinal  stiffness  or  deformity  and  for  pelvic  ob- 
liquity. It  is  placed  recumbent  and  later  procumbent  on 
a  couch  and  the  spine  examined  for  stiffness  and  antero- 
posterior and  lateral  deformity,  the  limbs  examined  for 
weakness,  wasting,  deformity,  and  inequality  of  length, 
and  the  larger  joints  for  pain,  heat,  tenderness,  swelling, 
stiffness,  and  spasm.  In  making  these  tests,  as  it  is  nec- 
essary to  get  the  child's  confidence,  all  abrupt  and  rough 
manipulation  should  be  avoided,  and  it  is  rarely  neces- 
sary to  cause  pain.  If  the  child  is  not  frightened  or  hurt, 
it  will  be  possible  to  distinguish  between  voluntary  and 
involuntary  resistance  to  joint  motion,  otherwise  diffi- 
cult. From  such  an  examination  one  should  be  able  to 
decide  whether  the  trouble  is  local,  central,  or  general, 
and  if  local  which  part  is  affected ;  secondly,  whether  the 
trouble  is  congenital,  traumatic,  static,  paralytic,  or  path- 
ological ;  if  pathological,  one  should  have  a  pretty  definite 


EXAMINATION  73 

idea  of  the  particular  nutritional  or  infective  change  in 
question,  and  be  able  to  decide  whether  the  process  has 
run  its  course  or  is  still  active. 

In  arriving  at  an  exact  diagnosis  the  examiner  is 
much  assisted  by  definite  information  on  certain  points 
in  child  physiology  and  pathology.  The  baby  should  hold 
its  head  up  and  begin  to  use  its  hands  at  three  months, 
sit  up  at  six  months,  creep  at  eight  months,  and  walk  and 
say  a  few  words  at  fourteen  months.  There  is  large  in- 
dividual variation,  but  failure  to  do  these  things  within 
two  or  three  months  of  the  usual  time  often  indicates 
^  disease  or  abnormality.  Failure  to  hold  up  the  head  or 
to  sit  up  at  the  proper  time  may  indicate  hydrocephalus , 
or  other  cerebral  defect,  idiocy,  malnutrition,  or  rickets. 
Creeping  has  an  important  educational,  gymnastic,  and 
prophylactic  value  and  should  be  encouraged;  unfortu- 
nately it  is  sometimes  curtailed  or  omitted.  Failure  to 
walk  at  one  and  one  half  to  two  years  may  indicate 
rickets,  myxedema,  joint  disease,  congenital  hip  disloca- 
tion, or  paralysis.  Unduly  delayed  talking  may  indicate 
unusually  slow  development  or  some  form  of  mental 
impairment. 

Young  babies  should  be  examined  by  the  obstetrician 
for  congenital  deformities,  and  also  after  difficult  labor 
for  birth  injuries,  including  head  injury,  sterno-mastoid 
injury,  brachial  plexus  rupture,  and  fracture  of  the  clav- 
icle, humerus,  and  femur.  In  the  first  six  months  the 
joint  infections  are  usually  purulent,  rarely  tuberculous ; 
in  the  second  six  months,  if  you  see  a  baby  with  tender 
epiphyses,  examine  for  scurvy.  Rheumatism  is  rare  in 
young  children,  very  rare  in  infants,  and  in  monarticular 


74  EXAMINATION   AND   DIAGNOSIS 

form;  though  the  various  joint  infections,  scurvy,  and 
the  attacks  of  poliomyelitis  are  often  so  diagnosed. 
From  the  second  to  the  fifth  year,  rachitic  deformities, 
joint  and  spinal  tuberculosis,  and  poliomyelitis  are  very 
common.  Poliomyelitis  often  passes  for  an  attack  of  in- 
digestion until  the  fever  subsides  and  weakness  in  the 
legs  is  noticed;  congenital  hip  dislocation  is  rarely  dis- 
covered until  the  child  begins  to  walk.  The  static  de- 
formities due  to  overweighting,  nonrachitic  weak  an- 
kles, knock-knees,  round  back,  and  scoliosis  occur  after 
infancy  and  through  adolescence.  The  typical  age  for 
the  development  of  coxa  vara  and  nonpathologic  pos- 
tural spinal  deformities  is  from  eight  to  fifteen.  Such 
troubles,  except  coxa  vara,  are  not  painful ;  even  the  flat- 
foot  of  childhood  is  usually  painless.  Striking  symp- 
toms often  indicate  trouble  at  a  distance,  as  the  knee 
pain  of  coxitis  and  the  abdominal  pain  of  spondylitis. 
Night  cries  are  frequently  symptomatic  of  spinal  or  joint 
disease.  In  many  cases  of  bone  and  joint  disease  a  good 
X-ray  plate  is  a  valuable  diagnostic  aid.  When  the  diag- 
nosis is  in  doubt  a  subsequent  examination  should  be  in- 
sisted on.  The  writer  recommends  the  careful  examina- 
tion of  all  children  at  birth  and  at  least  once  a  year 
thereafter,  in  order  to  detect  and  correct  deforming 
affections  in  their  incipiency.  Many  serious  conditions 
are  painless  and  extremely  insidious  and  easily  escape 
parental  observation  for  years.  It  is  the  duty  of  the 
family  doctor  to  recognize  beginning  deformity,  and  by 
timely  measures  to  preserve  the  symmetry  and  com- 
petence of  the  bodily  framework. 

In  the  examination  of  adults  much  the  same  plan  is 


HISTORY  75 

followed.  When  it  is  not  advisable  to  remove  all  the 
clothing,  at  least  a  generous  exposure  of  the  suspected 
parts  and  their  surroundings  should  be  required,  and 
the  important  regions  of  the  body  may  be  bared  suc- 
cessively, if  not  all  at  one  time.  Inquiry  as  to  the  gen- 
eral health  and  other  previous  and  present  affections 
should  never  be  omitted.  One  cannot  treat  a  part  prop- 
erly without  knowing  something  of  the  whole.  The  state 
of  the  digestion  and  elimination,  of  the  thoracic,  abdom- 
inal, and  pelvic  organs,  and  of  the  nervous  and  vascular 
systems  is  particularly  important,  also  past  or  recent  ex- 
posure to  infection,  A  youth  consulted  the  writer  re- 
cently for  flat-foot.  He  admitted,  after  questioning,  a 
recent  infection,  and  proved  to  be  suffering  also  from 
gonorrheal  endocarditis.  If  this  information  had  not 
been  elicited  neither  the  foot  nor  the  boy  could  have  been 
successfully  treated.  Thus  in  adults,  as  in  children,  the 
entire  individual  should  be  considered,  both  in  the  exam- 
ination and  in  the  therapy. 

History. — One  should  be  familiar  with  the  value  of 
evidence  in  order  not  to  be  lost  among  vague,  incorrect, 
or  conflicting  statements.  All  children  have  falls  and  it 
is  often  difficult  to  decide  the  relation  of  a  particular 
injury  to  subsequent  disease.  Fractures  are  not  infre- 
quently diagnosed  as  contusions  or  sprains.  Osteomye- 
litis may  develop  soon  after  injury.  Tuberculosis  of  a 
joint  may  appear  one  to  three  months  after  an  injury, 
which  is  usually  moderate  in  character.  Sarcoma  of  bone 
frequently  develops  a  few  weeks  after  an  injury,  and 
may  come  on  very  early.  The  bearing  of  the  family  his- 
tory has  already  been  mentioned.    Personal  habits  of  life 


76  EXAMINATION    AND    DIAGNOSIS 

are  often  important.  Many  parents,  especially  the  more 
ignorant,  will  unhesitatingly  assert  that  early  deform- 
ities are  congenital;  this  is  in  many  cases  erroneous. 
Observation  is  also  often  at  fault  as  to  the  duration  of 
deformity  in  older  children  and  adults.  A  flat-foot  or 
a  lateral  curvature  may  attract  no  notice  from  the  family 
or  the  patient  until  it  has  progressed  for  years.  If  the 
child  does  not  complain  little  attention  is  paid  to  its 
shape,  among  certain  classes.  On  the  other  hand,  certain 
mothers  are  overanxious  and  are  worried  about  trivial 
or  imaginary  blemishes. 

Records  of  cases  should  be  kept  in  books  or  on  cards 
with  photographs,  tracings,  measurements,  and  X-rays. 


Fig.  33. — Taking  Angle  of  Flexion  at  Knee  with  Lead  Tape. 

Contours  may  be  taken  with  a  flexible  lead  tape  20 
inches  long,  f  inch  broad  and  y^  inch  thick.  This  may 
be  molded  to  the  part  and  traced  off  on  paper  by  marking 


LABORATORY   AIDS 


77 


along  its  edge  with  a  pencil  (Fig.  33).  Angles  may  also 
be  taken  with  the  lead  tape,  or  with  a  small  protractor 
used  as  a  goniometer  (Fig.  34).    A  very  useful  method 


Fig.  34. — Taking  Angle  of  Flexion  at  Knee  with  Homemade  Gonio- 
meter; Cost  Four  Cents. 

of  record  for  deformities  of  the  limbs  is  to  trace  an  out- 
line of  the  part  on  a  piece  of  paper  or  directly  into  a 
large  record  book,  by  drawing  beside  it  with  a  pencil. 
A  front  tracing  will  give  a  good  record  of  bow-legs  and 
knock-knees,  while  with  the  leg  on  the  side,  angular  de- 
formity at  the  knee  and  foot  and  anterior  tibial  curves 
are  shown.  Careful  tracings  of  the  limbs  as  well  as 
measurements  are  indispensable  in  ordering  braces. 

Laboratory  aids  such  as  the  examination  of  blood,  fluids, 
and  tissues,  and  the  administration  of  bacterins  and  anti- 
toxins are  to  be  used  as  indicated,  the  latter  sparingly, 
the  former  freely.  The  X-ray  apparatus  often  gives  in- 
dispensable information  and  should  be  largely  used.  It 
is  to  be  noted,  however,  that  the  clinical  study  of  the  case 


78  EXAMINATION    AND    DIAGNOSIS 

should  precede  the  laboratory  report  and  that  the  latter, 
including  the  skiagraphic  appearance,  should  be  inter- 
preted in  the  light  of  the  former.  Scientific  aids  to  clin- 
ical investigation  should  occupy  a  secondary,  though 
often  an  important  place,  and  the  violation  of  this  rule 
has  resulted  in  errors  as  lamentable  as  they  were  un- 
necessary. 

Skiagraphy. — Many  cases  are  cleared  up  by  one  or 
more  good  skiagrams.  The  fluoroscope  is  of  practically 
no  value  in  orthopedic  work;  a  clear  negative  is  neces- 
sary, and  for  dense  tissues  like  an  adult  hip  the  com- 
pression blend  is  required.  A  poor  skiagram  is  usually 
worse  than  useless;  it  is  frequently  misleading;  poor 
skiagrams  are  commoner  than  good  ones.  It  is  often 
necessary  to  take  two  or  more  views  of  an  object  to  show 
an  abnormality.  A  fracture  may  not  show  from  the  side, 
when  it  will  be  perfectly  plain  from  the  front  or  vice 
versa.  It  may  be  necessary  to  repeat  a  skiagram  after 
a  certain  interval  to  note  possible  change.  The  earliest 
skiagraphic  indication  of  a  beginning  bone  disease  is 
diminished  density  (bone  rarefaction)  on  the  affected 
side.  When  the  bone  disease  recedes,  the  skiagram  will 
show  increasing  density  before  the  improvement  is  clin- 
ically evident  (Freiberg).  In  arthritis  deformans  one 
will  see  lessened  joint  interval  (condensation  of  carti- 
lage), bone  atrophy,  and  perhaps  osteophytes.  The  ap- 
pearances in  a  dislocated  hip  or  coxa  vara  are  usually 
obvious.  It  is  often  well  to  take  corresponding  parts  on 
the  same  plate  for  comparison. 

Diffuse  tuberculous  bone  infiltration  is  not  shown  in 
the  skiagram  (Konig).    Joints,  especially  the  hip,  may 


PEEVENTION  79 

appear  ankylosed  in  the  plate,  when,  in  fact,  considerable 
motion  is  present.  In  order  to  prove  bony  ankylosis  by 
skiagram  individual  striae  must  be  traced  from  bone  to 
bone. 

Considerable  experience  is  necessary  to  correctly  in- 
terpret X-ray  plates,  if  the  subjects  are  at  all  obscure  or 
difficult.  The  first  essential  is  a  working  knowledge  of 
bone  anatomy,  including  centers  of  ossification  and  con- 
genital anomalies. 

PREVENTION 

The  prevention  of  crippling  affections  is  partly  a 
medical  but  largely  a  social  question.  It  has  to  do  with 
the  nutrition,  training,  and  occupations  of  childhood  and 
adult  life.  The  vast  majority  of  children,  and  even  of 
those  afterwards  crippled,  are  born  healthy  and  suffi- 
ciently symmetrical.  The  problem  is  to  keep  them  so. 
Whatever  makes  for  vigor  should  be  emphasized.  At 
first  the  most  important  thing  is  proper  and  sufficient 
food,  and  this  continues  important  through  the  growing 
period,  and  indeed  through  life.  Improper  feeding  in 
infancy  is  responsible  for  marasmus,  rickets,  scurvy,  and 
much  of  anemia  and  lack  of  vigor.  Then  comes  the  fresh- 
air  life,  with  plenty  of  sunshine  in  the  temperate  zone; 
in  the  tropics  they  have  too  much.  Exercise  in  proper 
amount  and  variety,  diversion,  play,  and  a  bright  and 
cheerful  disposition  are  all  important.  In  a  word  it  is  a 
question  of  the  hygiene  of  childhood,  which  up  to  the 
age  of  six  is  largely  a  family  problem,  and  is  intimately 
connected  with  the  earning  power  of  the  father,  and  the 
intelligence  and  home  efficiency  of  the  mother.     Prom 


80  PKEVENTION 

six  on  the  unsolved  problem  of  school  hygiene  comes  in 
to  complicate  matters,  and  after  the  age  of  fourteen,  and 
often  earlier,  the  burning  questions  of  child  labor  and 
mother  labor.  The  liquor  and  tobacco  habits  are  im- 
portant, especially  in  childhood  and  in  relation  to  parent- 
age. In  the  United  States  the  strenuous  life  undoubtedly 
atfects  childhood  unfavorably.  Children  do  things  un- 
suited  to  their  age  and  condition,  and  often  do  them  too 
hard ;  it  must  be  said  that  the  indolent  life  is  even  worse. 
Children  are  often  encouraged  to  walk  and  stand  too 
early,  and  many  acquire  foot,  leg,  and  back  deformities 
in  this  way.  Spitzy  has  pointed  out  that  creeping  is  a 
valuable  physical  training  for  the  infant,  and  should  be 
prolonged  rather  than  abridged.  Indeed  there  is  a  nor- 
mal sequence  of  movements,  occupations,  and  interests 
which  should  not  be  interfered  with.  The  serious  culti- 
vation of  instrumental  music  is  undoubtedly  depressing ; 
vocal  training,  however,  is  favorable  to  health. 

The  prevention  of  infection  is  important,  and  prog- 
ress is  being  made  in  the  matters  of  a  purer  water  and 
milk  supply,  and  in  the  better  training  of  the  laity  in 
the  aseptic  treatment  of  wounds,  even  when  trivial.  In- 
vigoration  is  probably  after  all  the  best  protection,  as 
all  are  exposed  to  infection;  the  less  vigorous  succumb. 
The  best  training  a  child  can  receive  from  a  physical 
point  of  view  is  the  training  to  adjust  himself  to  the  or- 
dinary conditions  in  which  he  lives,  which,  like  cold  or 
draughts,  may  be  deleterious  or  beneficial,  according  as 
the  child  has  led  a  free  or  a  hothouse  life.  In  our  cities, 
houses  and  schoolrooms  are  usually  kept  too  warm,  and 
children  are  too  much  afraid  of  a  cold  splash.    The  ma- 


PROGNOSIS  81 

jority  of  one  class  of  infections,  the  venereal,  which  often 
lead  to  bone  disease  and  deformity,  may  be  prevented  at 
will,  by  avoiding  exposure. 

The  prevention  of  deformity  should  include  the  culti- 
vation of  normal  postures  in  the  ordinary  activities  of  life 
and  the  avoidance  of  too  prolonged  standing  and  sitting. 

When  a  crippling  affection  is  once  declared,  the  pre- 
vention of  deformity  is  an  important  part  of  the  surgical 
problem;  and  the  keys  are  early  diagnosis  and  adequate 
treatment.  Deformity  is  prevented  by  limiting  the  dura- 
tion and  severity  of  the  underlying  cause  through  proper 
treatment,  and  by  special  measures,  mechanical  or  oper- 
ative, to  keep  or  place  the  affected  part  in  the  posture  of 
greatest  safety  and  usefulness. 

PEOGNOSIS 

The  prognosis  in  the  commonest  deforming  diseases 
is  decidedly  good  as  regards  recovery.  Rickets  is  self- 
limited  and  curable;  scurvy,  rapidly  curable;  syphilis, 
gonorrhea,  pus,  and  other  infections  amenable  to  treat- 
ment. Bone  and  joint  tuberculosis  is  curable  in  the  ma- 
jority of  cases,  and  if  germs  remain  latent  they  do  not 
prevent  in  many  instances  long,  active,  and  useful  lives. 
Very  much  may  be  done  for  arthritis  deformans.  The 
most  frequent  congenital,  rachitic,  and  paralytic  deform- 
ities of  the  limbs  may  usually  be  corrected  with  restora- 
tion of  locomotion,  though  many  of  the  essential  palsies 
are  incurable.  Even  adult  and  neglected  cases  of  joint 
ankylosis  in  bad  posture  and  many  other  deformities 
can  be  readily  corrected  and  the  limb  restored  to  useful- 
ness.    Severe  deformities  of  the  spine  and  thorax  are 


82  TREATMENT 

resistant  to  treatment,  but  can  usually  be  prevented  by 
proper  management. 

This  generally  favorable  prognosis  depends  mainly 
upon  two  factors,  early  diagnosis  and  appropriate  treat- 
ment, both,  of  which  the  general  practitioner  should  be 
prepared  to  give  in  a  majority  of  the  cases.  They  are 
seen  early  much  oftener  by  the  family  doctor  than  by  the 
specialist,  and  if  recognized  then,  simple  treatment  will 
often  suffice.  It  should  also  be  generally  known  that 
even  severe,  neglected,  and  adult  cases  can  often  be  re- 
lieved; they  should  not  be  permitted  to  go  through  life 
with  serious  disabilities,  which  are  perfectly  remediable. 
The  prognosis  in  many  of  the  deformities  and  crippling 
affections  of  adult  life  is  nearly  as  favorable  as  in  child- 
hood. 

TREATMENT 

TREATMENT  OF  UNDERLYING  CAUSE 

General  Indications. — The  first  indication  in  the  treat- 
ment of  a  crippling  affection  is  to  cure  the  disease  or 
toxemia  causing  the  deformity,  if  that  disease  is  still 
active.  Rickets,  scurvy,  gonorrhea,  syphilis,  tuberculo- 
sis, require  special  treatment,  which  is  always  important 
and  frequently  successful.  Curing  the  disease  will  some- 
times remove  the  deformity,  as  in  many  cases  of  scurvy 
and  syphilis. 

It  is  often  necessary  to  treat  or  remove  infective  foci 
at  a  distance  from  a  joint  disease. 

The  second  important  general  indication  is  to  in- 
crease general  vigor;  this  is  particularly  necessary  in 
tuberculous   disease,   and   in   the    static,   pressure,    and 


TREATMENT  OF  UNDERLYING  CAUSE   83 

occupation  deformities.  This  is  best  done  by  constant 
exposure  to  fresh  air  and  sunshine,  and  by  giving  a  sim- 
ple but  nutritious  diet,  including  fresh  or  fermented  milk, 
eggs  and  fats,  with  meat,  vegetables,  and  fruits,  and  ex- 
cluding a  redundancy  of  starches  and  sweets.  Water 
should  be  freely  given,  and  elimination  facilitated.  Deep 
breathing  and  training  in  correct  postures  are  often  val- 
uable aids.  It  is  also  important  to  regulate  the  physical 
and  mental  activity  of  the  patient  by  the  proper  distribu- 
tion of  rest,  recreation,  and  exercise,  and  to  enforce 
hygienic  conditions.  School  work,  home  study,  piano 
practice,  and  hours  for  play,  rest,  and  sleep  will  require 
the  physician's  attention.  A  hopeful,  happy,  and  tran- 
quil mind  is  a  distinctly  favorable  factor. 

Special  Indications. — In  many  cases,  while  general  treat- 
ment is  important,  it  is  nevertheless  insufficient  to  con- 
trol the  local  process,  and  the  affected  part  must  be  im- 
mobilized, relieved  of  pressure,  and  otherwise  protected 
in  order  that  the  focal  disease  may  run  a  more  favorable 
course.  Abscesses  or  joint  cavities  may  require  aspira- 
tion or  incision,  and  surgical  operations  may  be  neces- 
sary to  remove  pathological  fluids  or  diseased  tissues.  A 
favorable  effect  on  repair  may  be  exerted  by  modifying 
the  local  circulation  by  strapping,  bandaging,  counter- 
irritation,  heat,  venous  congestion,  and  in  other  ways. 
Counterirritation  by  tincture  of  iodin  and  blisters  has 
lost  its  former  commanding  position,  but  iodin  is  useful 
in  connection  with  bandaging  and  strapping  in  super- 
ficial inflammations  such  as  simple  bursitis  and  teno- 
synovitis ;  small  blisters  or  the  Paquelin  cautery  may  be 
of  real  service  in  certain  neuralgic  and  painful  affections. 


84  TREATMENT 

Bier's  treatment  by  venous  congestion  or  "  dammed 
circulation  "  produced  by  an  elastic  band  applied  to  the 
affected  extremity  between  the  trunk  and  the  lesion  is 
highly  recommended  by  the  Germans,  and  is  deserving 
of  trial.  It  is  used  in  tuberculous,  purulent,  and  other  in- 
fections of  the  joints  and  soft  parts,  and  even  in  arthritis 
deformans.  The  three-inch  rubber  bandage  should  be 
applied  by  five  or  six  overlapping  turns  firmly  enough  to 
constrict  the  veins  but  not  the  arteries  of  the  limb;  the 
pulse  beat  should  be  as  distinctly  felt  as  on  the  other 
side.  Soon  after  the  application  congestion  of  the  limb 
distal  to  the  band  is  noticed,  which  increases  until  the 
color  is  purplish.  The  limb  should  remain  warm  and 
without  pain;  if  whitish,  cold,  or  painful  the  bandage 
should  be  loosened.  The  bandage  may  be  left  in  place 
one  hour  or  longer,  once  or  twice  a  day.  Short  sessions 
are  usually  sufficient  in  chronic  cases,  but  in  tuberculous 
joints  the  treatment  must  be  continued  more  than  a  year, 
and  splint  protection  should  not  be  neglected.  In  acute 
infections,  where  the  method  shows  its  best  results,  much 
longer  sessions  up  to  eleven  hours  on  and  one  off  are 
practiced;  the  limb  should  be  carefully  watched  to  pre- 
vent possible  accidents. 

The  regulation  of  posture  is  often  important.  The 
rachitic  baby  should  often  be  kept  from  standing  and 
sitting,  and  creeping  and  recumbency  should  be  encour- 
aged. Prolonged  sitting  and  standing  should  be  cur- 
tailed in  the  posture  deformities  of  the  trunk,  and  pro- 
longed standing  and  long  walks  discouraged  in  weak  and 
flat  feet,  bow-legs,  and  knock-knees.  Special  shoes  must 
be  fitted,  and  these  may  be  made  to  assist  the  correction 


COMPLICATIONS  85 

of  foot  and  leg  deformities;  waists,  corsets,  and  sus- 
penders must  be  correctly  adjusted  in  postural  cases. 
The  proper  treatment  of  crippling  disorders  will  in  most 
cases  include  the  prevention  of  deformity. 

Frames,  jackets,  corsets,  and  braces  will  often  be 
required  for  traction  or  immobilization  and  to  fulfill 
other  definite  indications. 

COMPLICATIONS 

A  few  words  may  be  said  about  the  general  manage- 
ment of  abscesses  and  sinuses,  ankylosis  and  atrophy, 
since  these  are  common  and  important  complications  of 
orthopedic  affections,  and  misapprehension  in  regard  to 
their  treatment  is  widely  prevalent. 

Abscesses  when  due  to  or  infected  by  pus  organisms, 
causing  local  and  constitutional  symptoms  and  containing 
true  pus,  should  be  evacuated  and  drained  at  once.  The 
collections  of  fluid,  flocculi,  and  necrotic  tissue  ^  known 
as  cold  abscesses,  but  which  are  really  pockets  or  cysts, 
are  usually  harmless  so  long  as  they  remain  uninfected. 
If  there  is  much  fluid  or  much  tension,  the  fluid  may  be 
drawn  off  with  the  aspirator.  One  or  more  tappings 
cause  the  disappearance  of  the  fluid  in  a  certain  number 
of  cases,  but  usually  it  collects  again  and  finally  opens 
or  is  incised.  A  second  mode  of  treatment,  which  has 
the  advantage  of  allowing  shreds  and  coagulge  of  consid- 
erable size  to  escape,  is  to  make  an  incision  one  half  inch 
long,  evacuate  the  contents,  close  the  incision  with  a  sin- 
gle stitch,  and  seal  with  collodion.  One  or  more  of  such 
evacuations  may  cause  a  disappearance  of  the  abscess. 

•  It  is  proposed  to  call  this  fluid  ichor  to  distinguish  it  from  pus. 


86  TREATMENT 

A  third  method  of  treatment  is  to  make  a  large  incision, 
curet  the  abscess  wall,  remove  diseased  bone  if  found, 
and  try  to  get  healing  by  granulation  from  the  bottom. 
This  also  sometimes  succeeds  and  frequently  fails.  The 
tendency  among  the  most  experienced  is  to  treat  cold 
abscesses  conservatively;  extensive  incisions  and  scrap- 
ings frequently  diffuse  the  infection  and  are  not  nearly 
so  common  as  formerly.  Some  eminent  surgeons  never 
open  an  ichor  pocket  (cold  abscess),  and  claim  brilliant 
results  from  aspiration  and  injection  with  iodoform  (sat- 
urated solution  in  ether,  or  ten-per-cent  emulsion  in  ster- 
ilized olive  oil)  or  camphorated  naphthol  (Calot).  The 
truth  is  that  these  pockets  usually  run  a  benign  course 
under  any  rational  method  of  treatment,  provided  the  un- 
derlying bone  or  joint  disease  is  recognized  and  properly 
managed,  otherwise  they  do  badly.  Sinuses  often  result 
under  any  method  of  treatment,  and  as  often  under  radi- 
cal as  conservative.  Such  sinuses  should  be  kept  clean 
and  will  sometimes  heal  under  injections  of  tincture  of 
iodin  or  of  iodoform-ether  solutions,  or  after  operations 
to  remove  dead  tissue.  Lately  the  suction  glass  (Bier) 
has  been  highly  praised ;  this  should  be  applied  daily  five 
minutes  on  and  three  minutes  off  for  half  an  hour.  It 
is  often  impossible  to  heal  them  by  any  method  and  a 
scanty,  thin  discharge  lasting  years  or  decades  often 
does  no  harm,  disagreeable  as  it  is.  The  appearance  or 
opening  of  a  pocket,  if  the  latter  is  properly  managed, 
does  not  necessarily  add  to  the  gravity  of  the  case;  it 
not  infrequently,  by  relieving  internal  tension  and  dis- 
charging necrotic  tissue,  ushers  in  permanent  improve- 
ment. 


COMPLICATIONS  87 

Since  the  above  was  written  the  injection  of  abscess 
cavities  and  sinuses  with  bismuth-vaselin  paste  has  been 
highly  extolled  both  for  diagnosis  and  treatment  (E.  Gr. 
Beck).  After  drying  the  sinus  with  a  strip  of  gauze,  one 
part  of  bismuth  subnitrate  (free  from  arsenic)  is  mixed 


Fig.  35.  —  Shows  Pockets  and  Sinuses  Mapped  Out  with  Bismuth- 
Vaselin  Paste.  The  patient,  a  child  of  six,  had  a  pocket  (abscess) 
over  the  hip;  the  proper  diagnosis  of  tuberculosis  of  the  sacrum  was 
not  made  until  this  skiagram  was  taken.  After  five  or  six  injections,  the 
discharge  had  nearly  ceased.     (Hospital  for  the  Ruptured  and  Crippled.) 

with  two  parts  of  boiling  vaselin,  sterilized,  cooled  to 
110°  or  less,  and  slowly  injected  from  a  dry,  sterile  glass 
syringe.  The  paste,  which  is  prevented  from  escaping 
by  a  gauze  pad,  distends  all  the  ramifications  of  the 
sinus,  and  as  bismuth  is  impervious  to  the  X-ray,  a  clear 


88  TEEATMENT 

picture  of  the  topography  of  the  pockets  and  sinuses 
may  be  obtained  (Fig.  35).  For  old  sinuses  a  quantity 
of  white  wax  and  of  soft  paraffin,  each  equal  to  one  sixth 
of  the  weight  of  the  bismuth,  may  be  added  to  increase 
the  solidity  of  the  mixture.  One  per  cent  of  formalin 
may  also  be  added  if  desired.  Many  obstinate  cases  have 
healed  under  one  or  more  such  injections,  and  the  method 
seems  to  be  a  real  advance.  Lately  ichor  pockets  have 
been  opened  and  immediately  injected  with  the  harder 
bismuth-vaselin  mixture  with  good  results. 

Ankylosis. — Of  the  several  elements  of  deformity,  stiff- 
ness, shortening,  weakness,  and  malposition,  malposition 
and  weakness  are  certainly  the  worst.  Ankylosis  of  hip, 
knee,  or  ankle  in  a  good  posture  affects  locomotion  so 
little  as  to  be  scarcely  noticeable ;  the  same  may  be  said 
of  moderate  shortening,  say  up  to  two  or  three  inches,  if 
properly  compensated  by  a  cork  sole.  Even  the  stiff 
elbow  or  shoulder  in  the  position  of  choice  gives  a  very 
useful  arm.  Some  grades  of  paralysis,  a  dangle  joint,  a 
straight  elbow,  or  a  much  flexed  knee  or  hip,  even  with  a 
fair  amount  of  motion  and  no  real  shortening,  is  a  ca- 
lamity, preventing  any  satisfactory  use  of  the  member. 
When,  however,  corresponding'  major  joints  on  the  two 
sides  are  stiffened,  as  the  two  xnees,  hips,  shoulders,  or 
elbows,  or  when  joints  are  ankylosed  that  cannot  be  com- 
pensated by  other  parts,  as  the  maxillary  joints  or  the 
cervical  vertebrae,  the  interference  with  function  is  seri- 
ous, and  it  is  in  such  cases  that  an  operation  to  produce 
a  pseudarthrosis  or  a  movable  joint  on  one  side  may  be 
indicated.  Joints  have  been  successfully  transplanted 
from  one  part  of  the  body  to  another  (great  toe  to  elbow, 


COMPLICATIONS  89 

Buchmann),  and  from  amputated  limbs  (Lexer).  There 
is,  however,  far  too  much  fear  of  stiffened  joints.  In 
dangle  and  paralyzed  joints  ankylosis  in  proper  position 
is  a  positive  benefit,  and  is  often  intentionally  produced 
(arthrodesis)  to  add  to  the  stability  and  efficiency  of  the 
limb.  Normal  joints  may  be  fixed  for  an  indefinite  time 
(many  years)  without  fear  of  ankylosis;  it  is  only  in- 
flamed joints  that  become  permanently  stiff.  Anything 
that  tends  to  reduce  or  limit  the  inflammation,  even  im- 
mobolization,  tends  to  preserve  the  integrity  of  the  joint 
and  its  ultimate  mobility.  Anything  that  increases  the 
joint  irritation  causes  an  increase  of  destructive  action 
and  of  adhesive  inflammation.  Injudicious  passive  or 
forced  movements  in  the  active  stage  of  disease  often 
do  this.  Forcible  manipulations  under  anesthesia  are 
frequently  indicated  after  disease  has  subsided,  but  when 
disease  is  still  present,  rest,  and  often  fixation,  are  re- 
quired. It  is  a  safe  rule  not  to  persist  in  manipula- 
tions that  cause  severe  general  or  local  reaction,  or  are 
followed  by  increased  stiffness.  The  fear  of  ankylosis 
with  some  amounts  to  a  mania,  and  much  harm  and 
suffering  have  been  caused  by  ill-advised  and  useless 
manipulations. 

Atrophy. — ^Another  persistent  error  relates  to  the  sig- 
nificance of  atrophy,  against  which  the  therapeutic  bat- 
teries are  often  directed  with  misguided  zeal.  Disuse 
from  pain,  tenderness,  stiffness,  weakness,  or  from 
splinting,  causes,  if  long  continued,  considerable  atro- 
phy, and  this  atrophy  is  not  confined  to  the  muscles,  but 
affects  all  the  tissues  including  the  bones.  There  is  a 
rapid  atrophy  which  is  one  of  the  early  symptoms  of 


90  TEEATMENT 

acute  and  clironic  bone  affections,  and  which  is  called 
reflex;  its  cause  is  still  in  doubt.  There  is  also  retarda- 
tion of  growth;  for  example,  in  a  case  of  juvenile  hip 
disease,  whether  splinted  or  not,  after  some  months  all 
the  bones  on  the  affected  side,  including  the  long  bones, 
the  foot,  the  pelvis,  and  the  patella,  are  rarefied  in 
structure  and  smaller  in  all  dimensions.  This  wasting 
in  the  course  of  years  may  amount  to  several  inches  in 
the  length  of  the  limb.  Notwithstanding,  neither  reflex 
atrophy  nor  the  atrophy  of  disease  ever  causes  a  true 
palsy  of  the  muscles  or  nerves.  Their  function  is  al- 
ways manifest  up  to  the  point  permitted  by  joint  con- 
ditions. Knees  have  been  restored  to  motion  that  have 
been  fixed  by  adhesions  for  many  years  (up  to  ten  or 
more),  but  not  a  case  has  been  reported  where  the  mus- 
cles controlling  such  a  joint  necessarily  wasted  by  long 
disuse  did  not  resume  their  function.  Nothing  more 
useless  can  be  imagined  than  for  the  surgeon  to  order 
massage  or  electricity  for  the  atrophy  of  a  beginning 
joint  disease,  and  take  no  measures  to  protect  the  joint. 
Paralytic  or  essential  atrophy  is  undoubtedly  serious, 
and  merits  serious  treatment.  It  is  the  writer's  belief, 
however,  that  nothing  helps  the  cold  and  wasted  leg  fol- 
lowing an  infantile  paralysis  so  much  as  the  shortening 
of  stretched  muscles  and  the  use  of  the  limb  in  locomo- 
tion. Paradoxically,  even  a  wasted  muscle  may  regain 
power  when  movement  is  prevented.  Robert  Jones  has 
pointedly  called  attention  to  the  fact  that  muscles  para- 
lyzed and  atrophied  for  years,  after  poliomyelitis,  devoid 
of  voluntary  power,  and  where  electric  reactions  de- 
noted complete  paralysis,  may,  if  shortened  and  held  in 


TREATMENT  OF  DEFORMITY      91 

the  shortened  position,  recover  considerable  power  in  the 
course  of  a  few  months.  If  by  the  wearing  of  a  proper 
supporting  brace  or  an  appropriate  arthrodesis  the 
function  of  locomotion,  which  has  been  impossible  be- 
fore, can  be  restored,  greater  benefit  to  the  circulation, 
nutrition,  and  strength  of  the  leg  will  accrue  than  from 
years  spent  in  a  chair,  with  daily  electricity  and  massage 
to  the  nerves  and  muscles.  Dry  heat  and  vibration  are 
valuable  stimulants  to  nutrition. 

TREATMENT  OF  DEFORMITY 

We  have  already  seen  that  during  the  active  stage 
of  deforming  affections  the  treatment  of  the  underlying 
cause  is  often  the  vital  and  usually  an  essential  indi- 
cation. The  treatment  of  the  deformity  itself  has  for  its 
object  a  restoration  to  normal  form  and  function,  or 
to  as  near  the  normal  as  the  conditions  permit.  Early 
orthopedic  work  in  this  country  relied  mainly  on  me- 
chanical means  both  for  correction  and  retention;  later 
the  operative  methods  become  more  popular.  At  pres- 
ent, not  only  in  this  country  but  in  Europe,  the  most 
eminent  authorities  rely  largely  upon  forcible  manipu- 
lations and  cutting  operations  for  the  correction  of  se- 
vere deformities.  In  some  locations  (the  spine)  such 
methods  are  not  applicable,  and  the  general  tendency  is 
toward  the  adoption  of  the  simplest  method  that  will 
quickly  and  safely  accomplish  the  result.  The  modern 
point  of  view  is  not  nearly  so  operative  as  ten  years  ago 
(rejection  of  early  resections  in  joint  disease,  and  of 
bone  operations  in  club-foot,  conservative  treatment  of 
"cold  abscesses").     Modern  orthopedic  practice,  while 


92  TREATMENT 

radical  in  its  aims  (early  and  quick  correction)  is  con- 
servative in  its  means.  Orthopedic  surgery  is  distin- 
guished from  general  surgery  mainly  in  its  point  of  view. 
The  orthoi^edic  surgeon  is  thinking  of  the  ultimate  re- 
sults, and  is  prepared  to  use  means  which  make  him 
independent  of  time.  When  operations  are  done,  they 
•are  done  to  prepare  the  way,  to  remove  the  obstacle,  to 
effect  some  definite  result,  but  are  often  only  an  inci- 
dent or  a  stejo  in  the  treatment,  not  its  principal  or  cul- 
minating feature.  Much  stress  is  laid  on  what  the  sur- 
geon calls  after-treatment ;  in  other  words,  the  treatment 
is  varied  at  different  times  and  stages  to  meet  varying 
requirements. 

Besides  the  usual  medical  and  surgical  means,  of 
which  it  makes  free  use,  orthopedic  surgery  has  devel- 
oped certain  methods  into  special  prominence  and  util- 
itj^     These  are: 

I.  Bandaging,  strapping,  splinting,  and  apparatus — 
mechanical  treatment. 

II.  Manual  and  oj^erative  correction — operative  treat- 
ment. 

III.  Exercises  and  gymnastics — gymnastic  treatment. 
Mechanical. — (a)   The  roller  bandage  is  used  to  limit 

motion,  or  to  atford  support  and  compression,  as  in  joint 
eifusion  and  varicose  veins.  Lacings  and  elastic  stock- 
ings and  caps  are  often  better. 

(b)  For  continuous  firm  compression  adhesive  plas- 
ter strapping  is  very  convenient  and  effective — joint 
effusions,  strains,  sprains,  flat-foot.  Adhesive  plaster 
also  affords  a  firm  basis  for  traction. 

(c)  Fixation  appliances  may  be  plastic — best  of  plas- 


TREATMENT-  OF    DEFORMITY  93 

ter  of  Paris — applied  directly  to  the  part  or  molded 
over  a  plaster  cast. 

The  plaster  splint  has  been  carried  to  great  perfec- 
tion. It  may  be  fixed  or  removable.  The  fixed  plaster 
splint  has  the  great  advantages  that  it  is  easily  applied 
and  that  it  remains  in  place  until  removed  and  cannot 
be  tampered  with.  It  has  the  disadvantage  of  unclean- 
liness  and  liability  to  excoriation,  and  even  constriction, 
if  imperfectly  applied  or  left  on  too  long.  Its  advantages 
have  caused  its  general  adoption  for  fixation  in  most 
orthopedic  clinics  in  this  country  and  in  Euroi^e.  Some 
very  eminent  men,  however,  do  sj^lendid  work  without 
using  plaster  at  all. 

Removable  splints  and  jackets  may  be  molded  over  a 
cast  taken  from  a  i^laster  splint  used  as  a  negative.  Such 
splints  may  be  made  of  plaster,  leather,  felt,  i^aper,  cel- 
luloid, aluminium,  and  other  materials.  They  are  made 
to  lace  or  hook  together. 

Lastly,  fixation,  traction,  correction,  or  supporting 
splints  may  be  made  of  an  annealed  steel  framework 
lined  with  leather,  and  secured  by  strips.  With  metal 
splints  the  direction  and  amount  of  motion  may  be  con- 
trolled at  will  at  the  various  joints,  and  they  are  largely 
used,  but  usually  require  to  be  made  by  an  experienced 
instrument  maker,  after  designs  to  suit  the  requirements 
of  the  case  in  hand.  Wire  or  metal  splints,  if  not  jointed, 
may  be  readily  manufactured  by  any  mechanic. 

Operative. — Correction  of  moderate  degrees  of  deform- 
ity may  often  be  made  by  the  repeated  apj)lication  of 
plaster  splints  with  moderate  manipulation.  Ordinary 
cases  of  infantile  club-foot  are  frequently  best  treated 


94  TREATMENT 

in  this  way.  Correction  of  even  severe  deformity  may 
frequently  be  effected  by  portative  apparatus  in  skilled 
hands,  but  the  process  is  rather  slow. 

It  is  the  merit  of  modern  methods  to  have  given  us 
means  for  rapidly  and  safely  overcoming  the  severest 
deformities  under  anesthesia  (Phelps,  Lorenz),  usually 
but  not  always  at  one  sitting.  This  may  be  done  by  for- 
cible manipulation,  with  or  without  appliances  (wedge, 
redresseur,  osteoclast),  and  is  especially  useful  in  club- 
foot, congenital  hip  dislocation,  and  fibrous  ankylosis. 
Rachitic  bow-legs  may  be  manually  corrected  in  children 
under  three  or  four. 

For  many  severe  deformities  of  bones  and  joints, 
and  in  the  older  cases,  osteotomies  are  indicated,  which 
may  usually  be  linear  and  subcutaneous.  Excision,  and 
even  amputation,  may  be  exceptionally  required.  Bones 
may  be  readily  adjusted  to  any  required  position,  and 
even  when  rachitic  readily  unite. 

In  the  last  few  years  tenoplasty  has  had  an  extraor- 
dinary vogue.  Tendons  have  been  lengthened,  shortened, 
and  grafted  with  great  frequency,  and  often  with  fair 
success.  A  simple  tenotomy  is  usually  all  that  is  needed 
to  lengthen  a  tendon,  since,  unless  infected,  the  tendon 
always  unites  by  strong  cicatricial  tissue.  Tenotomies 
of  heel  cord,  plantar  fascia,  and  adductors  of  thigh  may 
be  subcutaneous;  in  most  other  locations  they  should  be 
open  or  half  open  (tendon  hooked  up  through  small  in- 
cision), in  order  to  thoroughly  divide  contracted  tissues 
without  danger  to  vessels  and  nerves.  Tendons  may  be 
shortened  by  doubling,  or  by  straight  or  oblique  division, 
lapping,  and  suture.     The  tendon  of  an  active  muscle 


TREATMENT.  OF  DEFORMITY      95 

may  be  sutured  wholly  or  in  part  to  the  tendon  of  a 
paralyzed  muscle,  to  replace  the  latter  in  function,  or 
the  paralyzed  tendon  may  be  grafted,  with  or  without 
division,  to  the  healthy  tendon.  Tendons  may  also  be 
sutured  to  the  periosteum,  or  drawn  through  a  channel 
in  a  bone ;  they  may  be  lengthened  by  silk  threads.  The 
suture  material  is  braided  silk  No.  1  or  2,  and  strict  asep- 
sis must  be  observed.  If  much  deformity  is  present,  it 
is  best  to  correct  it  before  the  grafting,  and  the  opera- 
tion should  not  usually  be  done  before  the  age  of  eight 
or  ten.  Tendon  transplantation  is  most  used  in  the  pal- 
sies of  anterior  poliomyelitis,  and  it  was  hoped  that  the 
function  of  paralyzed  muscles  would  be  sufficiently  re- 
placed to  enable  the  patient  to  walk  without  apparatus. 
This  is  not  usually  the  case.  Many  cases  are  unsuccess- 
ful, and  in  those  which  are  successful  the  result  is  a  cor- 
rected and  more  stable  position,  but  not  usually  the  res- 
toration of  muscular  control. 

This  partial  disappointment  has  led  to  the  develop- 
ment of  arthrodesis  or  artificial  ankylosis.  Here  the 
joint  is  opened,  the  surfaces  are  denuded  of  cartilage 
and  remodeled,  as  desired,  and  the  limb  fixed  in  the  pos- 
ture of  choice.  The  results  here,  especially  at  the  ankle 
and  knee,  are  very  good.  A  fibrous  ankylosis  at  the 
ankle  is  the  rule  with  a  stable  and  useful  joint.  This 
operation  may  be  combined  with  tendon  grafting.  The 
best  results  will  be  obtained  by  postponing  this  opera- 
tion till  after  the  tenth  year. 

Gymnastic  treatment  may  have  the  stretching  and 
mobilization  of  contracted  tissues  and  the  relief  of  de- 
formity for  its  object,  as  in  round  back,  scoliosis,  and 


96  TREATMENT 

weak  foot.  It  may  be  assisted  by  special  apparatus 
(pressure  frame,  bars,  trapeze,  stretcher),  and  consists 
in  active  and  passive  movements  in  free  and  assisted 
gymnastic  exercises,  and  in  manipulations.  Special  pos- 
tures are  much  used  in  taking  the  exercises — creeping, 
lying,  sitting,  suspension,  and  others.  Light  gymnastics 
and  breathing  exercises  are  also  used  with  special  at- 
tention to  posture,  for  their  favorable  effect  on  carriage 
and  on  the  general  health.  The  foundation  of  correct 
posture  is  the  straight  (in  line  of  thrust),  weight-bearing 
foot.  This  is  the  proper  base  in  standing  and  walking, 
and  not  the  out-toeing  foot  of  the  conventional  gymnast 
and  soldier  on  parade.  One  should  also  strive  for  a 
straight  back,  high  chest,  and  moderately  retracted  chin, 
abdomen,  and  scapulae.  Besides  its  corrective  purpose, 
special  gymnastics  aim  to  strengthen  parts  which  have 
been  weakened  by  disease  or  disuse,  and  to  improve 
carriage  by  imparting  more  vigorous  tone  to  the 
muscles. 

Massage  is  of  moderate  value  in  orthopedic  practice. 
It  has  been  overused  and  overrated.  An  efficient  vibra- 
tor, on  the  other  hand,  run  by  an  electric  motor,  and  in 
skilled  hands,  gives  excellent  results  in  backache,  nerv- 
ous depression,  and  many  neuralgic  and  local  affections. 
It  combines  a  deep  massage  with  a  powerful  and  rapid 
shaking,  and  probably  assists  the  circulation  and  drain- 
age; whether  it  is  capable  of  producing  the  powerful 
reflex  effects  claimed  by  some  is  uncertain.  It  should 
be  used  with  a  definite  purpose,  and  according  to  a  defi- 
nite technic. 

The  tendency  has  been  to  exaggerate  the  results  of 


TREATMENT  OF  DEFORMITY      97 

gymnastic  treatment.  Too  much  lias  been  claimed  for 
it;  it  has  often  been  used  too  exclusively,  and  without 
discretion.  Properly  employed  it  is  capable  of  giving 
results  of  great  value  in  a  restricted  class  of  cases. 

The  different  kinds  of  electric  current,  hydrotherapy, 
light,  heat,  the  vibrator,  and  other  physical  methods  of 
treatment  are  of  great  value  in  increasing  local  circu- 
lation and  nutrition. 


SPECIAL  PART 


SPECIAL    PART 


DEFORMITIES    OF    THE    NECK    AND    TRUNK 

DEFORMITIES    OF    THE    NECK 

Torticollis,  or  wry-neck,  is  symptomatic  of  several 
affections,  and  maj^  be  congenital  or  acquired.  The  form 
of  most  surgical  interest  is  that  due  to  shortening  of  the 
sternocleidomastoid  muscle  of  one  side.  This  may  be  a 
congenital  condition,  but  it  may  also  be  due  to  an  injury 
of  the  muscle  at  birth. 

In  congenital  torticollis  the  deeper  neck  muscles  and 
other  structures  may  also  be  involved,  and  there  may  be 
anomalies  of  one  or  more  cervical  vertebrae  (osseous  tor- 
ticollis). Wedge-shaped,  defective,  fused,  and  atypical 
vertebrae  occasionally  occur,  causing  stiffness,  and  some- 
times shortness,  of  the  neck,  curvature  of  the  cervico- 
dorsal  spine,  and  tilting  and  rotation  of  the  head. 

Acquired  sternomastoid  torticollis,  the  typical  wry-neck, 
from  the  orthopedic  standpoint,  may  be  due  to  a  partial 
rupture  of  that  muscle  at  birth ;  a  hematoma  is  formed, 
which  is  followed  by  fibroid  degeneration  and  shortening, 
which  approximates  the  mastoid  process  of  the  affected 
side  to  the  episternal  notch ;  the  head  is  tilted  toward  the 
affected  side,  and  the  chin  upward  and  away  from  it 
(Figs.  36  and  37).    On  attemjDting  to  correct  the  deform- 

101 


102    DEFORMITIES    OF    NECK    AND    TRUNK 

ity,  the  shortened  muscle  stands  ont  as  a  tense  band.  In- 
fants with  torticollis  are  occasionally  seen,  in  whom  the 
hematoma  can  be  easily  felt  as  a  resistant  tender  swell- 
ing in  the  body  of  the  muscle.    Frequently  the  results  of 


Fig.  36.  Fig.  37. 

Figs.  36  and  37. — Right  Sternomastoid  (Birth)  Torticollis,  Girl  of 

Nine;  Untreated  Case.     Front  and  back  views  of  same  patient. 

the  early  injury  pass  unnoticed,  and  the  child  is  brought 
to  the  physician  months  or  years  later  for  the  neck  de- 
formity. At  this  time  the  swelling  may  have  disap- 
peared, and  there  is  no  tenderness  or  pain  on  motion, 
and  no  reflex  spasm.  If  much  time  has  elapsed  and  the 
deformity  is  marked,  the  corresponding  side  of  the  face, 
including  the  bones,  will  be  flattened  and  atrophied,  and 


DEFOEMITIES    OF    THE    NECK  103 

there  will  be  a  lateral  ])ending  and  often  a  fixed  curve 
of  the  upper  part  of  the  spine;  the  convexity  is  toward 
the  sound  side;  there  may  be  a  compensatory  curve  be- 
low in  the  opposite  direction. 

Early  and  slight  cases  may  be  cured  by  corrective 
manipulation  and  support  by  a  Thomas  collar  made  high 
on  the  side  toward  which  the  head  tips.  Portative  ap- 
paratus for  continuous  stretching  are  difficult  of  adjust- 
ment, and  usually  fail  of  radical  correction.  Most  of  the 
cases  after  infancy,  where  the  shortening  of  the  sterno- 
mastoid  can  be  readily  made  out,  require  a  tenotomy  of 
that  muscle. 

This  should  be  carefully  and  thoroughly  done  after 
three  years  of  age,  through  an  open  incision,  which  may 
run  parallel  to  the  clavicle  at  its  upper  border  for  about 
two  inches,  or  parallel  to  the  direction  of  the  muscle 
insertions.  The  two  tendons  should  be  separated  by 
blunt  dissectors,  hooked  up  and  divided.  The  jugular 
vein  lies  just  behind  the  sheath.  Contracted  parts  of 
the  sheath,  which  become  tense  under  corrective  manipu- 
lation, should  be  carefully  torn  or  divided.  The  neck 
and  upper  spine  should  be  thoroughly  manipulated,  and 
put  up  in  the  overcorrected  position  over  thick  cotton 
padding  in  a  plaster  splint  which  includes  the  jaw  and 
occiput,  the  neck,  the  shoulders,  and  upper  part  of  the 
thorax.  The  patient  should  be  carefully  watched  after 
the  operation,  to  prevent  choking  from  efforts  at  vomit- 
ing. Four  to  six  weeks  in  this  appliance  should  be  fol- 
lowed by  the  plaster  jacket  and  fixed  head  spring,  with 
tilting  and  rotative  action,  a  Thomas  collar  or  other 
appliance  (Fig.  38).     Corrective  manipulations  and  ex- 


104    DEFORMITIES    OF   NECK   AND   TEUNK 

ercises   should   also   be   employed   for    several   months. 
The  success  of  the  operation  depends  upon  its  thorough- 


FiG.  38. — Bratz  Apparatus  for  Torticollis.     (Sayre.) 

ness,  upon  fixation  in  overcorrection,  and  upon  the  after 
treatment;  when  these  are  not  adequate,  recontraction 
frequently  follows.     There  is  no  advantage  in  dividing 


DEFORMITIES    OF    THE    NECK  105 

the  muscle  below  the  mastoid  process  as  recommended 
by  Lange.  In  very  severe  cases  Mikulicz's  operation  of 
excising  the  lower  half  or  two  thirds  of  the  muscle  may 
be  employed. 

Another  injury  which  produces  a  characteristic  neck 
distortion  is  unilateral  dislocation  of  the  cervical  spine.  Owing 
to  their  nearly  horizontal  position,  an  articular  process 
in  the  cervical  region  may  become  displaced  forward 
upon  or  in  front  of  the  process  below,  without  fracture, 
and  usually  without  paralysis.  The  face  is  turned  away 
from  the  injured  side.  If  the  dislocation  is  upon  the 
articular  process  the  head  inclines  to  the  sound  side ;  if 
the  articular  process  is  dislocated  into  the  notch,  the 
head  leans  toward  the  injured  side.  The  reduction  is 
effected  without  traction,  the  patient  being  seated,  by 
rocking  the  head  away  from  the  dislocated  side  and  a 
little  backward,  to  disengage  the  dislocated  process,  and 
then  rotating  it  back  into  normal  position  (Walton). 
Reduction  may  be  effected  up  to  six  months  after  the 
injury.  In  bilateral  dislocation  spastic  paralysis  is  com- 
mon ;  the  head  is  displaced  forward  and  tilted  back. 

Wry-neck  from  Debility  and  Rickets. — Delicate  or  rachitic 
children  often  show  weakness  in  the  neck,  and  do  not 
hold  up  the  head  properly.  Aside  from  malnutrition  and 
rickets,  the  commonest  causes  of  failure  to  hold  up  the 
head  at  six  months  of  age  or  later  are  idiocy  and  hydro- 
cephalus. A  certain  number  of  delicate  children,  whose 
neuro-muscular  tone  is  defective,  habitually  turn  the 
head  to  one  side.  In  these  the  head  can  be  easily  straight- 
ened without  pain  or  resistance;  indeed,  the  child  may 
from  time  to  time  straighten  the  head  voluntarily. 


106    DEFORMITIES    OF    NECK   AND    TRUNK 

In  these  cases  the  nutrition  needs  attention,  and 
tonics  with  a  proper  diet  will  often  be  sufficient.  With 
increased  strength  the  child  holds  its  head  properly. 
Not  infrequently  a  thick,  broad  collar  of  cotton,  higher 
on  the  side  toward  which  the  head  tips,  and  retained 
by  several  turns  of  a  muslin  bandage  and  bound  by  ad- 
hesive plaster,  will  give  beneficial  support  for  a  few 
weeks. 

Acute  or  "  rheumatic  "  torticollis — better,  infectious  tor- 
ticollis— a  not  uncommon  atfection  in  the  second  septen- 
nium,  is  usually  due  to  an  infection  of  the  deep  tissues 
of  the  neck  through  the  tonsils  or  pharynx  during  or 
after  a  pharyngitis,  tonsillitis,  grippe,  or  other  acute  in- 
fectious disease.  The  invasion  is  acute,  with  fever  and 
constitutional  symptoms  during  or  after  a  sore  throat; 
the  neck  is  very  stiff,  and  the  head  often  turned  to  one 
side.  Movements  are  very  painful,  and  there  is  much 
local  tenderness.  The  acute  symptoms  last  only  a  few 
days  or  weeks,  but  adhesive  inflammation  sometimes 
cause  severe  and  permanent  stiffness.  It  is  not  prob- 
able that  there  is  anything  "  rheumatic  "  about  the  con- 
dition. The  throat  or  other  sources  of  infection  about 
the  neck  should  be  examined  and  properly  treated. 

For  the  neck  itself  rest  and  hot  fomentations  are 
necessary.  The  patient  should  be  kept  in  bed  so  long 
as  movements  are  painful — a  rule  which  is  often  violated 
— and  during  the  acute  stage  cloths  wrung  out  of  hot 
water  or  a  hot  poultice  should  be  applied  and  changed 
frequently.  After  the  subsidence  of  acute  symptoms  a 
thick  collar  of  cotton,  retained  by  muslin  bandages  and 
adhesive-plaster  strips  two  inches  wide,  should  be  applied 


DEFORMITIES    OP    THE    NECK  107 

until  normal  conditions  return.  If  the  neck  remains  per- 
manently stiff  and  twisted  after  subsidence  of  inflamma- 
tion, careful  manual  correction  under  an  anesthetic  may 
be  indicated. 

Any  injury  or  disease  which  affects  the  side  of  the 
neck,  and  results  in  extensive  swelling-,  inflammation,  or 
cicatricial  contraction,  may  cause  a  temporary  or  per- 
manent wry-neck.  Burns  and  tuberculous  or  suppurating 
glands  are  examples. 

Cervical  spondylitis  tuberculosa  is  frequently  accompa- 
nied by  a  gradually  increasing  stiffness  and  distortion 
of  the  neck.  Voluntary  movements  are  limited,  and 
passive  movements  are  more  or  less  resisted — reflex  or 
protective  spasm.  The  chin  usually  drops  toward  the 
chest,  and  does  not  point  to  the  opposite  side,  and  the 
sternomastoid  muscle  does  not  stand  out  as  a  tense 
cord.  The  patient  is  less  active,  and  may  hold  his 
chin  on  his  hands.  The  general  health  is  usually  af- 
fected, and  a  pocket  (abscess)  may  form  in  the  neck 
or  pharynx.  The  treatment  is  the  treatment  of  cervical 
Pott's  disease. 

Cervical  Spondylitis  Deformans. — The  neck  becomes  slowly 
stitfened  and  deformed.  This  stiffness  is  sometimes  con- 
fined to  the  uppermost  vertebrte,  sometimes  affects  the 
whole  neck,  and  sometimes  a  large  part  or  the  whole  of 
the  spine.  Other  joints  may  be  primarily  affected.  The 
cause  of  the  process  is  not  known ;  it  is  extremely  chronic, 
and  there  is  no  tendency  to  suppuration.  Pain  is  often 
present.  The  process  consists  in  an  osteoarthritis  of  the 
spine,  or  in  a  simple  atrophic  arthritis  without  osteo- 
phytes, but  with  a  tendency  to  ankylosis.     There  is  in 


108    DEFORMITIES    OF    NECK   AND    TRUNK 

both  more  or  less  absorption  of  the  intervertebral  discs, 
and  in  the  former  osteophytic  growths  about  the  periph- 
ery of  the  superior  and  inferior  surfaces  of  the  vertebral 
body. 

While  the  affection  seems  unpromising,  great  relief, 
and  sometimes  cure,  results  from  efficient  spinal  and 
head  support  and  tonic  treatment.  Depressing  remedies 
and  too  strict  diet  should  be  avoided.  Antirheumatic 
treatment  is  often  harmful. 

Spasmodic  and  spastic  torticollis  is  a  disease  of  adult  life 
due  to  irritation  of  nerve  centers  controlling  the  neck 
muscles.  It  may  be  characterized  by  sudden  clonic 
spasms  of  one  or  more  muscles  of  one  side  of  the  neck 
drawing  the  head  toward  the  shoulder,  and  sometimes 
rotating  it.  The  contractions  may  be  violent  and  fre- 
quently repeated,  or  fibrillary  and  tremorlike,  with  spas- 
ticity; the  disturbance  may  involve  both  sides,  and  may 
extend  to  other  parts.  The  irritation  is  sometimes  due 
to  intestinal  autointoxication;  good  results  have  been 
reported  from  the  correction  of  digestive  and  neurotic 
disturbances,  and  from  tonic  and  psychic  treatment, 
manipulation,  muscle  training,  the  high  frequency  cur- 
rent, and  intramuscular  injections  of  hyoscin  (Sachs), 
■^-Q  of  a  grain  once  or  twice  a  day,  carefully  watched, 
and  increased,  for  a  week  or  two  at  a  time.  Mechan- 
ical treatment  and  myotomy  are  usually  disappointing. 
In  resistant  cases  stretching  or  excision  of  the  spinal 
accessory  nerve,  and,  if  this  fails,  excision  of  the  cer- 
vical nerves  of  the  affected  side,  has  sometimes  proved 
successful. 

A  cervical  rib  may  occur  on  one  or  both  sides  of  the 


CHEST    DEFORMITIES     -  109 

seventh  cervical  vertebra;  it  is  usually  small  and  unno- 
ticed, but  may  cause  a  hard  prominence  at  the  base  of 
the  neck  and  press  upon  the  subclavian  vessels  or  bra- 
chial plexus,  and  interfere  with  the  circulation  and  in- 
nervation of  the  arm.  Deformed  and  atypical  vertebrae 
often  accompany  cervical  ribs,  causing  lateral  curvature 
of  the  cervico-dorsal  spine,  occasionally  of  other  regions. 
The  results  of  excision  of  the  redundant  rib  in  these 
severer  cases  are  excellent.  The  operation,  however,  on 
account  of  the  proximity  of  the  structures  above  men- 
tioned and  of  the  pleura,  may  be  a  rather  difficult  one. 
It  is  to  be  remembered  that  the  vessels  and  nerves  pass 
over  or  in  front  of  the  cervical  rib,  never  below  it,  and 
that  the  pleura  may  lie  almost  in  contact  with  its  inner 
border.  Through  an  incision  like  that  for  ligation  of  the 
subclavian  artery  the  vessels  are  exposed  and  drawn  to 
one  side,  the  rib  is  dissected  free  with  as  much  as  possi- 
ble of  its  periosteum,  and  removed. 

CHEST    DEFORMITIES 

The  normal  chest  varies  within  considerable  limits,  but 
it  is  characteristic  of  the  adult  human  thorax  to  have  a 
greater  transverse  than  antero-posterior  diameter  (3  to 
2).  The  infantile  chest  is  much  rounder,  and  more  prom- 
inent in  its  anterior  superior  part.  In  other  words, 
babies  are  more  full  chested  than  children  or  adults. 
The  primitive  or  simian  chest  is  more  elongated  and 
more  rounded  than  the  normal,  and  is  a  stigma  of  de- 
generation. It  is  such  chests  that  are  most  prone  to 
pulmonary  phthisis  (Hutchinson),  rather  than  the  flat 
chest.     The  emphysematous  chest  is  large  and  barrel- 


no  DEFORMITIES  OF  NECK  AND  TRUNK 


shaped — expiratory  chest.  Recent  authorities  claim  that 
susceptibility  to  bacterial  invasion  of  the  limgs  is  due 
to  a  small  heart  or  arteries,  rather  than  to  a  defective 
chest.  A  small  or  weak  chest  is  one  cause  of  shortness 
of  breath,  and  limits  bodily  efficiency. 

Congenital  Deformities 

Congenital  deformities  of  the  thorax  are  not  very  com- 
mon. The  sternum  may  be  fissured  or  perforated,  form- 
ing one  of  many  de- 
formities at  the  me- 
dian line  of  the  body, 
caused  by  imperfect 
fusion  of  the  primi- 
tive lateral  flaps. 
Other  examples  are 
cleft  palate,  spina  bi- 
fida, hypospadias,  ex- 
strophy of  the  blad- 
der, and  umbilical 
hernia.  Parts  of  one 
or  more  ribs  may  be 
absent,  causing  a  de- 
fect in  the  thoracic 
wall,  which  is  covered 
only  by  soft  parts 
(Fig.  39).  The  pectoral  muscles  of  one  side  may  be 
wholly  or  partly  absent,  a  defect  causing  surprisingly 
little  interference  with  the  use  of  the  arm. 

Funnel  chest  consists  in  a  marked  depression  of  the 
lower  end  of  the  sternum  and  the  adjacent  parts  (Fig. 


Fig.  39. — Defect  of  Ribs. 
(Osborne's  case.) 


CHEST    DEFORMITIES 


111 


40).  It  is  usually  symmetrical,  or  nearly  so.  Even  when 
extreme,  it  does  not  interfere  with  health  or  strength, 
and  is  incurable.  Funnel  chest  may  also  be  rachitic,  or 
due  to  certain  occupations. 

Eachitic  Defokmities  of  the  Chest 

Rachitic    Rosary. — The    swelling    of    the    costo-stemal 
junctions  forms  a  row  of  beady  prominences  at  the  sides 


Fig.  40. — Funnel  Chest  and  Pigeon  Breast. 


112    DEFORMITIES    OF    NECK   AND    TRUNK 

of  the  thorax  which  are  easily  palpable,  and  may  be  visi- 
ble; they  are  one  of  the  characteristic  signs  of  rickets. 
A  very  slight  enlargement  is  nearly  always  present  in 
infants,  and  is  not  abnormal.  The  rachitic  rosary,  like 
most  of  the  rachitic  stigmata,  tends  to  disappear  as  the 
child  grows  older. 

Harrison's  groove  is  a  depression  at  the  sides  of  the 
thorax,  due  to  pressure  of  the  air  and  of  the  flexed  arms. 
The  free  borders  of  the  ribs,  on  the  other  hand,  are  ab- 
normally prominent  from  the  outward  pressure  of  the 
enlarged  viscera. 

Pigeon  breast  {Pectus  carinatum)  is  the  keeled  ante- 
rior prominence  of  the  chest  caused  by  the  forcing  in  of 
the  sides  (Fig.  40).  It  may  be  extreme.  These  deformi- 
ties undoubtedly  affect  the  breathing  power  of  the  indi- 
vidual, but  it  does  not  appear  that  after  the  active  stage, 
lung  complications  are  more  common  in  the  rachitics  with 
severe  chest  deformities  than  in  others.  In  all  rachitics 
there  is  a  marked  tendency  to  catarrhs  of  the  air  pas- 
sages and  of  the  gastro-intestinal  tracts  during  the  active 
stage.  The  treatment  of  all  these  conditions  is  the  treat- 
ment of  rickets,  with  the  possible  addition  of  deep-breath- 
ing exercises.  Mechanical  treatment  is  of  doubtful  util- 
ity. In  most  cases  the  deformities  themselves  are  of 
secondary  importance. 

Certain  secondary  deformities  of  the  thorax  regularly 
result  from  the  antero-posterior  and  lateral  spinal  de- 
formities, and  from  tight  lacing;  long-continued  recum- 
bency flattens  the  chest,  behind  and  in  front,  especially 
in  children. 


DEFOKMITIES    OF    THE    SPINE  113 

DEFORMITIES    OF    THE    SPINE 
NoKMAL  Postures 

The  human  body  is  still  imperfectly  adapted  to  the 
upright  posture.  Too  little  activity  or  too  long  persist- 
ence in  standing  may  result  in  sagging,  and  ultimately 
in  important  structural  changes.  Hernias,  displacements 
of  the  abdominal  and  pelvic  viscera,  varicose  veins,  hem- 
orrhoids, flat-feet,  round  back,  and  lateral  curvature  are 
among  the  commonest  afflictions  of  mankind,  but  are  rare 
in  quadrupeds,  and  are  largely  due  to  the  mechanical 
stress  of  the  upright  posture  in  standing  and  sitting. 
Man's  time  is  mainly  divided  between  standing,  sitting, 
and  lying,  each  of  which  postures  permits  of  infinite 
variation.  Inactive  standing  and  sitting  are  unduly  pro- 
longed in  modern  life,  to  the  great  detriment  of  form  and 
posture. 

The  recumbent  posture  is  usually  one  of  relaxation, 
as  during  sleep,  and  the  weight  of  the  body  is  transmitted 
directly  to  the  supporting  surface  and  not  through  the 
spine,  pelvis,  legs,  and  feet,  as  in  standing;  it  is  conse- 
quently a  relief  to  overweighted  j^arts.  The  pillow 
should  be  low,  in  order  to  avoid  poking  the  head  for- 
ward. Procumbency  is  an  excellent  corrective  of  this 
tendency,  and  also  of  mild  grades  of  round  back.  In 
the  lateral  decubitus  the  upper  iliac  crest  is  prominent 
from  the  sagging  of  the  loin,  and  the  spine  is  concave  to 
the  upper  side  for  the  same  reason,  and  from  the  forcing 
upward  of  the  shoulders.  The  posture  is  of  some  use 
as  an  adjuvant  in  the  management  of  lateral  curvatures, 
and  may  be  maintained  in  sleep  by  strapjDing  a  spool 


114    DEFORMITIES    OF    NECK   AND    TRUNK 

on  the  hip  which  is  to  be  uxipermost.    The  patient  should 
lie  on  the  side  of  the  prominent  hip. 

In  the  sitting  posture  the  base  is  formed  by  the  but- 
tocks and  thighs,  which  are  then  analogous  to  the  feet 
in  standing.  The  back  may  be  supported  by  a  chair  or 
remain  free.  In  our  joresent  social,  educational,  and  in- 
dustrial life  the  sitting  posture  is  very  important.  The 
tendency  is  to  confine  the  body  too  long  to  this  posture, 
and  to  allow  too  little  freedom  in  it.  In  the  normal  sit- 
ting posture  the  thighs  are  directed  forward,  the  pelvis 
is  even  and  placed  as  far  back  in  the  seat  as  possible; 
as  the  feet  do  not  carry  the  weight  of  the  body,  they  may 
be  placed  in  various  positions,  but  should  rest  on  the 
floor.  The  back  is  held  straight,  but  not  rigid,  and  the 
trunk  may  be  swayed  forward,  backward,  or  to  either 
side  from  the  hip  joints  and  lumbar  spine  (Figs.  59  and 
60).  A  wide  variety  of  movements  should  be  encouraged, 
and  occupations  at  the  desk  or  bench  should  be  varied. 
With  all  precautions,  sitting  should  be  alternated  with 
standing  movements,  or,  better,  with  walking,  at  frequent 
intervals.  When  sitting  is  not  connected  with  an  active 
occupation,  much  latitude  may  be  allowed;  but  the  com- 
mon posture,  with  pelvis  forward  in  the  seat  and  a  tilted 
or  sagging  lumbar  spine,  contracted  chest,  cramped  vis- 
cera, and  protruded  chin,  the  posture  of  extreme  relaxa- 
tion, should  not  be  habitual.  The  problem  of  the  school 
desk,  of  the  seated  factory  ojjerative,  and  of  the  seden- 
tary life  cannot  be  solved  by  attention  to  the  sitting  pos- 
ture or  to  the  seat  and  desk  alone,  but  must  be  ap- 
proached from  the  point  of  view  of  general  development 
and  rational  hygiene.     Recesses,  change  of  occupation, 


DEFORMITIES    OF    THE    SPINE 


115 


and  corrective  exercises,  sports,  and  dancing  are  some 
of  the  means  that  should  be  employed  to  counteract  what 
is  really  a  serious  evil. 


Fig.  41. — Normal  (Straight-foot)  Walking  Posture. 
Igorrote  woman.     (Hoffmann.) 


The  upright  posture  is  the  one  best  fitted  for  activity. 
Its  inherent  instability  is  less  felt  and  its  evils  are  less 
conspicuous  during  action 


Prolonged  walking  is  less 


116    DEFORMITIES    OF    NECK   AND    TRUNK 


harmful  than  prolonged  standing,  and  climbing  is  less 
harmful  than  walking  on  hard,  level  surfaces.  When, 
however,  the  upright  posture  is  used  as  a  passive  or 
resting  posture  for  long  periods,  the  strain  on  the  back 

and  feet  often  becomes 
harmful,  and  may  result 
in  serious  disability.  The 
tendency  is  to  relapse  into 
postures  of  relaxation  and 
fatigue ;  prominent  inner 
ankle  bones,  outtoeing  and 
everted  feet,  and  a  round- 
ed back  with  prominent 
chin  and  abdomen  indicate 
the  lack  of  muscular  tone. 
The  strain  is  put  upon 
ligaments  instead  of  mus- 
cles; these  yield  in  the 
end,  and  habitual  vicious 
posture  and  structural 
changes  result.  While  much 
variety  of  posture  is  allow- 
able, and  even  desirable, 
the  foot  which  is  bearing 
the  weight,  the  active  or 
working  foot  in  standing 
and  walking,  should  be  di- 
rected forward  to  oppose 
the  forward  thrust  of  the 
body  (Fig.  41).  In  stand- 
ing, the  weight  should  be 


Fig.  42. — -Correct  Standing  Post- 
ure. Notice  straight  back, 
straight  feet,  forward  slant,  ab- 
sence of  hypertension,  and  free- 
dom from  exaggeration,  so  com- 
mon in  conventional  gymnastic 
postures. 


DEFORMITIES   OF    THE    SPINE  117 

frequently  shifted  from  one  foot  to  the  other.  The 
posture  of  the  pelvis  controls  the  spine,  and  conse- 
quently depends  largely  upon  the  posture  of  the  feet  and 
legs.  The  straight  back,  one  without  a  too  pronounced 
pelvic  tilt,  should  be  cultivated,  and  the  chest  should 
be  held  high  and  the  chin  and  abdomen  somewhat  re- 
tracted (Fig.  42).^  The  gymnastic  and  military  ideal 
of  rigidly  retracted  scapula  and  knees  is  both  offensive 
and  injurious. 

The  Spine 

The  spine,  consisting  of  the  sacrum  and  twenty-four 
presacral  vertebrae  with  their  elastic  discs,  is  nearly 
straight  in  infants,  and  acquires  the  lumbar  and  cervical 
concavity  and  dorsal  convexity  through  the  early  efforts 
at  sitting  and  standing.  The  curves  which  characterize 
adult  life  are  fairly  well  marked  about  the  seventh  year. 
The  column  is  most  flexible  in  the  cervical  region,  and 
least  in  the  dorsal.  Motion  may  take  place  in  the  sagittal 
(flexion  and  extension),  or  frontal  plane  (lateral  bend- 
ing), or  about  a  vertical  axis  (rotation).  The  lateral 
movements  are  normally  combined  with  rotation,  except 
in  the  lumbar  region. 

Congenital  Anomalies  of  the  Spine 

According  to  Dwight,  absence  or  surplusage  of  one 
or  more  vertebrae  is  not  excessively  rare.  The  common- 
est anomaly  of  number  is  to  have  eleven  or  thirteen  tho- 
racic vertebrae.    Wedge-shaped  half  vertebrae  may  occur 

1  The  posture  is  shown  somewhat  exaggerated  for  corrective  purposes  in 
Fig.  56. 


118    DEFORMITIES    OF    NECK   AND    TRUNK 


on  either  side  (Fig.  43),  or  two  unfused  halves  may  exist. 

Adjacent  vertebra?  may  be  wholly  or  partially  fused  on 

one  or  both  sides; 
lumbar  and  cervical 
ribs  may  occur  adja- 
cent to  the  thoracic 
spine,  and  the  tran- 
sitional vertebrae,  the 
seventh  cervical,  and 
the  first  and  fifth 
lumbar  are  often 
atypical.  Thus  the 
fifth  lumbar  may  be 
sacralized,    and    the 

Fig.  43.— Asymmetrical  Sacrum;  Six  Ver-  Sacralization  may  be 

TEBR^  ON  Right  Side,  Five  on  Left.  unilateral    or    asym- 
(From  specimen  in  College  of  Physicians 

and  Surgeons,  New  York.)  metrical,     and     COm- 


m  ^ 

^ 

^m  ^ 

_^M 

■  H 

#^  jflH 

^K.^ 

JF^J^^I 

^^^L% 

^.^^^H 

^^^^^^^^^^^^^^^k^^ 

id^lH 

Fig.  44. — Sacralization  of  Fifth  Lumbar  Vertebra,  More  Marked  on 
Left  Side.  The  specimen  to  the  right  is  more  completely  sacralized  and 
has  only  four  lumbar  vertebrae.  (From  specimens  in  Cornell  Medical 
College.) 


DEFORMITIES    OF    THE    SPINE  119 

bined  with  asymmetrical  fusion  (Fig.  44).  The  segment 
of  the  sacrum  articulating  most  largely  with  the  ilium 
is  called  the  vertebra  fulcralis.  Counting  the  sacral  seg- 
ments as  vertebrae,  this  is  normally  the  twenty-fifth,  but 
may  be  the  twenty-fourth  or  twenty-sixth. 

When  the  vertebral  arches  are  incomplete  the  con- 
dition, if  local,  is  called  spina  bifida;  if  it  involves  the 
greater  part  of  the  spine,  it  is  called  rachischisis.  In 
either  case  a  sac  containing  membranes,  and  often  nerve 
structures,  usually  protrudes,  and  various  anomalies  of 
the  soft  parts  occur.  Spina  bifida  is  often  complicated 
with  paralysis  and  deformity  of  the  feet  and  legs.  Sen- 
sation is  involved  as  well  as  motion,  and  pressure  sores 
are  easily  produced. 

It  is  well  to  remember  that  individual  spinous  proc- 
esses may  be  bifid  or  deviate  to  one  side  without  func- 
tional or  pathological  significance. 

Acquired  Deformities  of  the  Spine 

Antero-posterior  Postural  Deformities 

Round  back  or  round  shoulders  (kyphosis)  is  the  term 
used  to  designate  faulty  postures  in  which  the  posterior 
convexity  of  the  spine  has  increased  from  vicious  poise 
or  muscular  weakness.  Sometimes  the  whole  spine  is 
involved  in  the  backward  curve,  in  other  cases  the  round- 
ing is  principally  in  the  dorsal  region,  and  the  lumbar 
hollow  may  be  exaggerated.  In  the  common  form  the 
head  and  neck  sag  forward,  the  chin  is  protruded,  the 
shoulders  and  scapulae  slide  forward,  the  chest  is  sunken, 
the  viscera  are  cramped,  and  the  abdomen  is  prominent. 


120    DEFORMITIES    OF    NECK   AND    TRUNK 


It  is  a  posture  of  relaxation,  weakness,  and  fatigue.  It 
is  often  the  expression  of  a  general  condition,  and  fre- 
quently associated  with  weak  and  outtoeing  feet,  knock- 
knees,  and  lack  of  vigor.     As  a  matter  of  balance  it 

is  evident  that  when  the 
spine  is  projected  back- 
ward, some  part  of  the 
body  must  be  projected 
forward  as  a  counterpoise; 
the  parts  so  projected  are 
the  head  and  abdomen  or 
pelvis  (Fig.  45).  When 
round  back  is  allowed  to 
continue  it  may  become  a 
serious  fixed  deformity.  It 
is  probable  that  prolonged 
relaxed  sitting  is  in  many 
cases  an  important  causa- 
tive agent. 

Round  or  weak  back  is 
caused  by  overweighting 
of  the  spinal  column  or 
by  weakening  of  its  mus- 
cular and  bony  supports. 
The  overweighting  may  be 
due  to  too  long  confine- 
ment in  the  sitting  or 
standing  posture,  or  to  the 
carrying  of  loads,  as  in  the  case  of  grocers'  boys  and 
others,  or  to  a  combination  of  both.  Muscular  support 
is   weakened   by   any   condition   that    depresses   neuro- 


FlG. 


45.  —  Atonic   Round    Back; 
Girl  of  Fifteen. 


DEFORMITIES    OF    THE    SPINE  121 

muscular  tone,  such  as  congenital  or  acquired  weakness, 
convalescence,  overwork,  underfeeding,  fatigue,  and  old 
age;  also  certain  paralytic  affections.  Eound  back  may 
also  he  favored  by  imperfect  development  of  the  chest 
— primitive  chest — by  faulty  postures  in  which  trunk 
flexion  predominates,  and  by  unbalanced  muscular  ac- 
tion, as  in  the  round  back  of  boxers  and  certain  gym- 
nasts. Certain  children's  diseases  soften  bone,  weaken 
the  tissues,  and  depress  tone ;  such  are  rickets,  maras- 
mus, scurvy,  and  cretinism.  In  these  affections  the  sit- 
ting posture  often  results  in  a  posterior  projection  of 
the  spine,  of  which  the  rachitic  spine  is  typical.  In  such 
infants  sitting  should  be  forbidden,  and  recumbency  and 
creeping  substituted,  while  the  nutritional  disorder  is 
being  corrected.  There  are  also  a  number  of  trophic  and 
infectious  processes  affecting  the  spines  of  adults  which 
interfere  with  its  supporting  power,  and  often  result  in 
a  round  back  with  more  or  less  rigidity;  examples  of 
such  diseases  are  spondylitis  deformans,  osteoarthritis, 
ostitis  deformans,  and  acromegaly.  The  list  is  simi- 
lar to  that  of  the  causes  of  scoliosis,  but  in  that  de- 
formity the  cause  works  asymmetrically.  It  is  common 
for  slight  degrees  of  lateral  curvature  to  coexist  with 
round  back. 

School  life,  by  its  monotonous  confinement  to  the 
desk,  doubtless  tends  both  to  impair  vigor  and  to  flex  the 
spine,  and  is  an  important  cause  of  round  back.  Never- 
theless, round  back  often  affects  children  after  infancy 
and  before  school  age.  Such  children  are  often  rachitic, 
delicate,  or  physically  degenerate.  Round  back  may  be 
caused  by  the  muscular  weakness  and  faulty  postures 

10 


122    DEFORMITIES    OF    NECK   AND    TRUNK 

favored  by  an  occupation — cobbler,  tailor — but  a  boxer, 
gymnast,  or  blacksmith  may  have  a  round  back  and  also 
very  strong  muscles.  He  may  have  developed  his  mus- 
cles in  a  bad  posture,  or  the  spine  may  be  too  rigid  to 
be  held  in  proper  erectness. 

The  mental  element  in  round  back  is  frequently  im- 
portant. In  the  lethargic  and  dull  there  is  not  sufficient 
mental  stimulus  to  maintain  an  erect,  active,  and  effect- 
ive posture,  and  the  posture  becomes  careless  and  the 
back  rounded.  Round  back  and  flat  chest  may  be  due 
to  adenoids  and  nasal  obstruction,  and  may  be  favored 
by  near-sightedness. 

The  tendency  of  functional  round  back,  if  severe,  is 
to  become  structural  and  rigid,  if  uncorrected,  but  some 
paralytic  round  backs  are  abnormally  flexible. 

In  the  round  back  of  old  age,  as  in  other  senile  affec- 
tions, it  is  hard  to  draw  the  line  between  the  normal 
and  pathological.  Frequent  examples  of  perfect  erect- 
ness in  old  people  prove  that  the  sagging  spine  of  old 
age  is  not  inevitable.  On  the  other  hand,  the  aged  are 
especially  prone  to  spines  which  are  pathologically  stiff- 
ened and  weakened.  In  a  spondylitis  deformans  or  in- 
fectious arthritis  of  the  spine,  if  the  ankylosing  process 
proceeds  rapidly  the  spine  may  remain  straight,  but  if 
it  be  slow  and  accompanied  or  preceded  by  general  de- 
bility, the  spine  sags  and  acquires  a  posterior  or  lat- 
eral bend. 

Another  large  and  important  class  of  cases  originates 
before  or  about  puberty  in  school  or  industrial  life,  and, 
as  in  the  corresponding  class  of  scoliotics,  has  no  definite 
pathology  beyond  the  normal  or  exaggerated  laxity  of 


DEFORMITIES    OF    THE    SPINE  123 

tissue  common  at  that  period.  Some  of  these  cases  de- 
velop extreme  forms  with  great  rapidity,  and  become 
very  resistant ;  in  such  cases  there  is  doubtless  compres- 


FiG.  46. — Recruit,  16|;  Accepted  for  Navy,  February;  Discharged  for 
Round  Back  the  Following  June;  has  also  Weak  Feet. 

sion  of  the  intervertebral  discs  and  vertebral  bodies  on 
the  concave  side  (Fig.  46).  Prevention  is  to  be  sought 
in  the  conservation  of  vigor  and  a  better  hygiene  of 


124    DEFOEMITIES    OF    NECK   AND    TEUNK 

cliildhood  outside  as  well  as  inside  the  sclioolroom.  We 
should  work  for  better  conditions  of  living,  food,  light, 
air,  exercise,  and  play,  less  piano  practice  and  more 
singing,  more  sports,  games,  and  play  out  of  school, 
proper  seats,  desks,  air,  light,  exercise,  and  frequent 
change  of  posture  in  the  school.  One  of  the  stock  ques- 
tions of  a  distinguished  orthopedic  surgeon  in  posture 
cases  is:  "  TVlien  do  you  play?"  The  question  often 
evokes  astonishment  in  lieu  of  an  answer,  TTe  must  insist 
on  a  better  hygiene  of  the  shop,  factory,  and  tenement, 
more  reasonable  work  hours,  less  standing  and  sitting, 
more  variety  of  employment,  and  more  recreation  for  the 
child  and  for  the  mother.  So  long  as  any  considerable 
part  of  the  burden  of  civilization  is  borne  on  the  back 
of  the  child  and  of  the  woman,  just  so  long  will  those 
backs  bend  to  the  load.  Not  less  serious  is  a  hothouse 
life,  Vvdth  an  atmosphere  of  indolence,  limitation,  and 
tension. 

Diagnosis. — The  cases  due  to  weakness,  paralysis, 
and  pathological  conditions  should  be  carefully  distin- 
guished. The  term  kyphosis,  as  applied  to  round  back, 
is  unfortunate,  since  it  is  also  applied  to  the  deformity 
of  Pott's  disease,  from  which  it  must  be  sharply  dis- 
tinguished. The  Pott's  kyphosis  is  nearly  always  at  first 
the  sharjD  projection  of  a  single  spinous  jorocess;  it  is 
accomi^anied  by  spinal  stiffness,  characteristic  pain,  pos- 
ture, and  constitutional  symptoms.  The  ]3athological 
round  backs  of  adult  life  can  usually  be  distinguished 
by  their  stiifness  and  by  their  history. 

The  TREATMENT  of  postural  round  back  consists  in 
invigoration  and  lq  posture  trarQiag ;  in  structural  cases, 


DEFORMITIES-  OF    THE    SPINE  125 

mobilizing  and  corrective  exercises  are  useful.  General 
vigor  is  to  be  increased  by  improving  the  nutrition,  by 
attention  to  general  hygiene,  and  by  exercise;  posture 
training  may  be  given  by  means  of  selected  gymnastic 
exercises,  and  spinal  mobilization  by  suitable  exercises 
with  or  without  apparatus.  The  use  of  the  vibrator  to 
the  spinal  muscles  is  stimulating  and  refreshing.  The 
much-used  shoulder  braces  are  usually  useless,  and  fre- 
quently harmful ;  only  a  few  of  the  severer  cases  require 
spinal  support  by  jackets,  corsets,  or  braces  in  connec- 
tion with  the  gymnastic  work,  and  still  fewer  forcible 
correction.  The  matter  of  proper  clothing  support  is 
often  an  important  one.  Children's  clothing  should  be 
supported  by  straps  or  suspenders,  taking  their  base 
near  the  neck,  and  not  far  out  on  the  shoulders,  as  is 
unfortunately  the  practice  in  most  waists,  suspenders, 
and  similar  garments. 

The  gjnmnastic  work  should  not  be  confined  to  the 
trunk,  but  should  aim  at  harmonious  general  develop- 
ment; it  should  especially  aim  to  strengthen  the  feet, 
waist,  chest,  and  neck,  and  should  include  breathing  and 
balance  exercises.  Conventional  gymnastics  may  be 
made  useful,  but  are  often  defective  from  imperfect  sense 
of  posture,  and  from  an  unwise  selection  of  exercises. 
If  too  strenuous,  they  may  do  harm  to  delicate  children. 
Certain  sports  and  games,  like  swimming  and  basket 
ball,  involving  the  larger  muscles  of  the  torso,  are  often 
of  great  benefit. 

The  following  exercises  are  useful;  they  should  be 
practiced  slowly,  with  a  pause  at  the  end  of  each  move- 
ment, and  each  should  be  repeated  about  six  times: 


Fig.  47. — SwiiiiiixG  Moveiiext  1. 


Fig.  48. — Swimming  Movement  2. 


Fig.  49. — Leg  Raising,  Patient  Prone. 
126 


DEFORMITIES    OF    THE    SPINE 


127 


Lying  on  face. 

1.  (Swimming  movement.)     Head  and  shoulders  ele- 
vated, arms  stretched  forward,     {a)  Sweep  arms  back- 


FiG.  50. — Trunk  Raising;  Hands  Between  Scapula. 

ward  till  hands  are  over  hips;  (5)  bring  hands  to  shoul- 
ders; (c)  stretch  arms  forward  (Figs.  47  and  48). 


Fig.  51. — Trunk  and  Head  Raising;  Hands  Clasped  Behind. 

2.  (Leg  lifting.)     Hands  under  chin;  knees  straight. 
Extend  thigh;  alternate  right  and  left  (Fig.  49). 


128    DEFORMITIES    OF    NECK   AND    TEUNK 

3.  Hands  between  scaiDul^e.  Raise  trunk  (Fig. 
50),  or 

3A.  Elbows  straight,  hands  clasped  behind.  Extend 
trunk;  supinate  forearms,  bringing  thumbs  backward 
(Fig.  51).  The  feet  should  be  held  down  in  this  and  the 
preceding  exercise. 

Fig.  52  shows  a  corrective  resting  posture. 

Lying  on  hack. 

4.  Hands  behind  neck,  knees  straight.  Flex  thigh 
alternately  right  and  left.     Later  circle  thigh. 


Fig.  52. — Corrective  Resting  Posture  for  Round  Back. 

5.  Small  pillow  behind  chest.  Breathe  deeply ;  sweep 
arms  upward  to  limit  during  deep  inspiration,  and  de- 
press arms  to  side  during  expiration. 

Sitting. 

6.  Patient  sits  on  stool,  with  hands  clasped  behind 
neck,  and  bends  back,  while  the  operator  pulls  back  on 
the  elbows  and  presses  forward  with  his  knee  against 
the  curve  of  the  spine  (Fig.  53). 


DEFORMITIES    OF    THE    SPINE 

Hanging  from  trapeze  or  bar,  head  hack. 

7.  Separate  and  close  legs. 

8.  Twist  pelvis  to  right  and  left. 

9.  Operator  pushes  against  dorsal  convexity. 


129 


Fig.  53. — Correction  of  Round  Back  by  Knee  Pressure. 

Standing. 

10.  Swing  arms  forward  and  back,  or  walk  backward 
to  get  proper  poise  on  balls  of  feet. 


130    DEFORMITIES    OF    NECK   AND    TRUNK 

11.  Hands   clasped   behind  head,   elbows  well   back. 
Push  back  with  head  against  resistance  of  hands. 


Fig.  54. — Self-Correction  of  Rouxd  Back  by  Head  and  Spinal 
Extension,  Hands  Clasped  Behind. 

12.  Hands  clasped  behind  back,  elbows  straight. 
Bend  forward  at  hips;  extend  trunk;  arch  head  and 
spine  backward,  while  holding  arms  stiff  (Fig.  54). 

13.  Deep  breathing. 


DEFORMITIES    OF    THE    SPINE  131 

14.  One  foot  forward,  knee  bent,  body  inclined  for- 
ward, arms  stretched  out  in  front.  Swine:  arms  back 
horizontally.    Repeat  with  other  foot  forward. 

15.  Walk  with  shot  bag  on  head. 


Fig.  55. — Retraction  of  Head  Against  Resistance,  Hands  Against 
Wall,  for  Correction  of  Head  and  Spinal  Deviations. 

16.  Stand  two  feet  from  wall;  rest  separated  hands 
on  wall  at  level  of  shoulders,  elbows  straight.     Opera- 


132    DEFORMITIES    OF    NECK    AND   TRUNK 


tor's  hand  presses  patient's 
head  forward  (Fig.  55). 
Patient  pushes  head  strong- 
ly backward  against  resist- 
ance of  operator's  hand, 
pulling  chin  in. 

17.  Patient  stands  with 
upper  chest  against  wall, 
head  and  feet  slightly  re- 
tracted (Fig.  56). 

1,  3,  6,  9,  11,  12,  and  16 
are  particularly  corrective. 

All-around  invigoration, 
with  mobilization  through 
trunk  extension,  the  devel- 
opment of  weak  parts  and 
of  breathing  power,  and 
education  in  correct  pos- 
ture, is  the  aim  of  gymnas- 
tic treatment,  and  should 
result  in  habitual  maxim,wn 
self-correction,  which  is  of 
_^,^^__^  all  means  probably  the  most 

^■p  effective.     Consult  also  the 

section  on  round  shoulders. 
Lordosis. — There  is  consid- 
erable variation  within  nor- 
mal limits  in  the  amount  of  the  lumbar  hollow,  due  to  the 
inclination  of  the  pelvis  and  the  forward  bending  of  the 
lumbar  spine.    Certain  cases  of  round  back,  particularly 


Fig.  56. — Chest  Against  Wall; 
Correction  for  Round 
Back. 


DEFORMITIES    OF    THE    SPINE 


133 


in  the  dorsal  region,  are  associated  with  lordosis,  others 
are  rounded  throughout,  while  in  another  type  of  back 
the  upper  part  is  straight  and  the  lower  hollow.    Lordo- 


FiG.  57. — Lordosis  from  Bowed  (Rachitic)  Femora. 

sis  may  be  symptomatic  of  weakness  or  palsy  of  the 
lumbar  or  abdominal  muscles,  as  in  pseudo-hypertrophic 


134    DEFORMITIES    OF    NECK   AND    TEUNK 

muscular  atrophy,  or  to  other  causes  interfering  with 
the  balance  of  the  pelvis,  such  as  corpulence,  pregnancy, 
rickets  (Fig.  57),  bilateral  congenital  hip  dislocation, 
bilateral  coxa  vara,  flexed  hip,  spondylolisthesis,  and 
Pott's  disease.  The  treatment  of  lordosis  is  the  treat- 
ment of  the  primary  affection;  in  a  few  cases  jackets 
or  corsets  may  be  useful.  Many  cases  do  not  require 
treatment. 

In  normal  standing,  walking,  and  working  postures, 
lordosis  is  to  be  avoided,  as  it  is  both  inept  and  un- 
sightly, and  the  "  straight  back,"  with  but  a  slight  lum- 
bar concavity,  should  be  cultivated  in  daily  life,  and  in 
gymnastics  and  posture  work. 

Spondylolisthesis  is  the  name  given  to  a  sliding  forward 
of  the  body  of  the  fifth  lumbar  vertebra  upon  the  sacrum ; 
the  sliding  may  also  take  place  between  the  fourth  and 
fifth  lumbar.  It  is  most  frequent  in  pregnant  women 
owing  to  the  laxity  of  their  ligaments,  but  may  occur 
also  in  men,  with  or  without  violence.  Weakness  of  the 
back  and  lack  of  endurance  is  complained  of;  the  pelvis 
is  abnormally  horizontal,  the  iliac  crests  prominent,  and 
the  lumbar  spine  short  and  concave.  Palpation  may 
reveal  an  abrupt  sinking  of  the  corresponding  spinous 
process,  but  the  deformity  can  exist  with  the  arches 
so  stretched  out  that  no  depression  is  felt.  A  middle- 
aged  man  with  this  affection,  seen  by  the  writer,  had 
been  treated  without  benefit  by  exercise  for  neurasthenia 
for  a  year  or  more.  The  treatment  should  be  spinal 
support  by  a  plaster-of-Paris  corset  or  other  efficient 
appliance. 

Softening   of  the  lumbar  vertebrae  from  locomotor 


DEFORMITIES    OF    THE    SPINE  135 

ataxia  may  give  rise  to  displacements  easily  mistaken 
for  spondylolisthesis. 

Lateral  Deformities  of  the  Spine 

Scoliosis,  or  lateral  curvature  of  the  spine,  may  be  con- 
genital or  acquired;  there  is  also  an  intermediate  or 
latent  form  depending  upon  a  congenital  anomaly  of  the 
vertebrae,  which  may  determine  the  development  of  a 
scoliosis  some  years  later.  Acquired  scoliosis  is  by  far 
the  more  common  form,  and  may  be  functional  and  read- 
ily corrected  by  manipulation,  or  by  the  effort  of  the 
patient,  or  structural  and  persistent.  The  functional  ^ 
form  often  changes  into  the  structural,  if  neglected. 
Like  round  back,  scoliosis  is  often  secondary  to  patho- 
logical conditions,  general  or  local,  but  the  ordinary  cases 
are  postural,^  due  to  overweighting  or  decreased  spinal 
resistance  combined  with  one-sided  postures;  whether 
there  is  an  obscure  underlying  local  pathological  process 
is  still  under  discussion.  When  the  term  scoliosis  is  used 
without  qualification,  the  postural  form,  which  is  also 
the  commonest,  is  meant. 

The  CAUSES  OF  scoliosis  are  very  similar  to  those 
producing  round  back,  but  in  scoliosis  the  two  sides  of 
the  spine  are  unevenly  affected.  As  in  round  back,  the 
fundamental  difficulty  is  the  instability  of  the  trunk  in 
the  upright  posture.  Acquired  lateral  curvature  may  be 
divided  into  the  following  groups: 

I.  Postural  scoliosis  due  to  overloading  or  decreased 

'The  term  "functional"  is  used  to  designate  a  degree  of  the  affection, 
the  term  "postural."  to  denote  causation;  the  term  postural  is  used  by  some 
authors  in  the  sense  in  which  functional  is  used  here. 


136    DEFORMITIES    OF   NECK   AND    TRUNK 

resistance  in  growing  individuals  who  sit,  stand,  or 
work  in  faulty  and  one-sided  postures.  Some  oculists 
believe  that  habitual  faulty  postures  may  be  produced 
by  certain  forms  of  astigmatism  and  by  asjonmetrical 
weakness  of  the  eye  muscles.  A  unilateral  deafness  is 
also  said  to  favor  the  development  of  scoliosis. 

II.  Static  scoliosis  is  due  to  pelvic  obliquity,  usually 
from  a  short  or  flexed  leg. 

III.  Contraction  scoliosis  of  a  severe  type  follows 
pulmonary  collapse  and  pleuritic  obliteration  after  em- 
pyema. 

IV.  Paralytic  scoliosis  is  an  intractable  form  due  to 
asjinmetrical  palsy  of  spinal  and  trunk  muscles.  It  not 
infrequently  complicates  poliomyelitis,  Friedreich's  dis- 
ease, and  syringomyelia.  Pseudo-paralytic  or  spastic 
scoliosis  may  be  present  in  hysteria. 

V.  Pathological  scoliosis  results  from  certain  general 
and  local  diseases,  such  as  tuberculous  and  other  de- 
forming diseases  of  the  spine,  osteomalacia,  acromegaly, 
osteitis  deformans,  sciatica,  and  sacro-iliac  disease,  or, 
indeed,  any  disease  or  injury  having  a  one-sided  effect 
on  the  stability  of  the  spine. 

A.     Congenital  Scoliosis 

Congenital  scoliosis  is  not  common;  it  is  frequently  un- 
noticed until  some  months  after  birth.  The  early  cases 
are  often  single.  The  X-ray  may  assist  in  the  exact 
diagnosis,  and  may  clear  ujd  certain  of  the  older  cases, 
which  appear  to  have  developed  as  postural  cases,  but 
are  really  due  to  misshapen  vertebrae.  Treatment  is  dif- 
ficult, but  considerable  may  be  done  in  the  infantile  cases 


DEFORMITIES    OF    THE    SPINE  137 

by  attention  to  the  baby's  postures  on  the  mother's  arm 
and  elsewhere,  by  strapping  down  the  high  shoulder  with 
adhesive  plaster,  by  placing  a  thick  felt  pad  under  the 
prominent  side,  by  periods  of  recumbency  on  the  hollow 
side,  by  encouraging  creeping  and  procumbency,  or  by 
continuous  recumbency  on  the  padded  frame.  The  best 
results  in  the  single  cases  seem  to  be  obtained  by  pulling 
the  shoulder  and  thigh  on  the  convex  side  toward  each 
other,  by  a  soft  bandage  applied  to  the  side  of  the  neck 
on  the  concave  side,  crossing  itself  through  a  slit  over 
the  high  shoulder,  crossing  itself  through  another  slit 
over  a  felt  pad  over  the  convexity,  passing  under  the 
thigh  of  the  same  side  to  be  pinned  to  the  other  end, 
thus  pulling  the  flexed  thigh  upward.  The  two  ends  of 
the  bandage  and  the  crossings  are  pinned.  This  removes 
the  curvature,  and  allows  the  child  to  bend  toward  the 
former  convexity,  but  not  toward  the  former  concavity. 

B.     Acquired  Scoliosis 

I.  Postural  (Habit)  ScoHosis. — This  is  the  largest,  most 
important,  and  least  understood  group.  A  "  high  shoul- 
der "  or  "  high  hip  "  is  usually  first  noticed  by  the  mother 
or  dressmaker  at  the  age  of  seven  to  twelve;  in  other 
words,  in  the  early  school  years.  Girls  are  more  fre- 
quently affected  than  boys,  but  when  boys  are  affected 
the  deformity  is  often  excessive  and  intractable.  It  usu- 
ally, but  not  always,  occurs  in  delicate  and  neurotic 
children. 

It  has  been  pointed  out  that,  if  an  infant  is  carried 

constantly  on  the  same  arm  of  the  nurse,  an  obliquity  of 

the  baby's  pelvis  occurs,  which  produces  a  spinal  bend- 
11 


138    DEFORMITIES    OF    NECK   AND    TRUNK 

ing;  such  a  bending  might  become  fixed  in  a  rickety  or 
marantic  child.  The  weight  of  the  baby  on  one  arm  may 
cause  a  lateral  correction  in  the  nurse  if  the  latter  is  a 
delicate,  growing  girl.  When  in  acquired  cases  the  dis- 
tortion develops  before  school  age  there  is  usually,  but 
not  always,  a  rachitic  basis.  In  a  large  number  of  chil- 
dren it  is  an  occupation  (school)  deformity  due  to  pro- 
longed sitting  in  faulty  postures,  and  with  too  little  ac- 
tivity. In  others  it  may  be  provoked  by  carrying  the 
schoolbooks  or  a  baby  on  one  arm,  usually  the  left;  New 
York  grammar  school  children  carry  habitually  five 
pounds  of  books  to  and  from  school  (Gulick).  Or  it 
may  be  due  to  certain  habits  or  tricks  of  standing,  sitting, 
or  lying,  or  to  all  of  these.  It  is  doubtful,  however,  if 
such  faulty  postures  alone  usually  cause  the  trouble. 
Another  factor  seems  to  be  necessary,  namely,  the  weak- 
ened resistance  of  the  osseous  and  neuro-muscular  ap- 
paratus, either  by  rickets  in  early  childhood,  by  an 
exaggeration  of  the  normal  laxity  characteristic  of  the 
pubertal  and  prepubertal  periods,  or  by  some  process  not 
understood.  Of  late  much  importance  has  been  attached 
to  the  sitting  posture  at  the  desk,  and  it  has  been  sought 
to  remedy  the  evils  of  faulty  desk  postures  by  improving 
the  seat  and  desk,  and  by  introducing  the  vertical  style 
of  writing.  The  latter  has,  however,  been  criticised  both 
from  the  practical  and  the  hygienic  point  of  view,  and 
seems  to  be  losing  ground  in  this  country.  The  school 
desk  should  clear  the  knees,  and  should  be  low  enough 
for  the  arm  to  rest  on  it  comfortably  without  bending 
the  back;  its  top  should  slope  about  fifteen  degrees. 
The  seat  should  be  of  such  height  that  the  feet  will  rest 


DEFORMITIES    OF    THE    SPINE  139 

easily  on  the  floor.  The  height  of  the  desk  and  seat  should 
therefore  be  adjusted  to  the  pupil.  The  seat  should  be 
placed  at  a  sufficient  distance  to  allow  a  moderate  for- 
ward inclination  of  the  body  in  writing.  The  seat  should 
be  hollowed  for  the  thighs  and  buttocks,  and  should  be 
slightly  higher  in  front;  its  front  edge  should  not  pro- 
ject more  than  one  inch  under  the  desk.  The  back  of 
the  chair  should  be  flat  and  narrow,  and  slightly  inclined 
backward,  and  should  be  open  behind  the  buttocks.  It 
should  support  the  back  below  the  waist  (lumbo-sacral 
junction),  and  in  the  lower  half  of  the  dorsal  region,  in- 
cluding the  lower  angle  of  the  scapulae  when  the  pupil 
is  reading  or  resting.  All  the  edges  of  a  school  chair 
should  be  rounded. 

The  chair  recently  devised  by  Miss  Emma  J.  Sebring, 
principal  of  St.  Agatha's  School,  New  York  City,  seems 
to  the  writer  to  be  a  distinct  advance,  and  by  far  the 
best  yet  offered  for  sedentary  occupations  (Fig.  58). 

"  This  chair  is  designed  with  the  distinct  purpose  of 
at  least  inviting  or  encouraging,  if  not  compelling,  cor- 
rect sitting  posture.  It  is  maintained  that  the  only  com- 
fortable position  in  this  chair  is  the  correct  sitting  posi- 
tion, and  that  when  this  position  is  taken  the  chair  is 
perfectly  comfortable. 

"  Correct  sitting  posture  involves  free  movement  of 
the  trunk  backward,  forward,  and  sidewise  on  the  hip 
joints;  a  straight  spine,  supported  just  below  the  waist 
and  at  the  shoulder-blades,  elsewhere  free,  and  held  very 
nearly  at  right  angles  with  the  thighs ;  square  shoulders ; 
erect  chest,  and  feet  resting  squarely  on  the  floor  (Figs. 
59  and  60). 


140    DEFOEMITIES    OF    XECK   AND    TRUNK 

"  The  folloTving  advantages  are  claimed  for  this 
chair : 

"  1.  It  is  not  screwed  to  the  floor,  and  may  therefore 
be  pushed  backward  or  forward  at  varying   distances 


Fig.  58. — Miss  Emma  G.  Sebrixg's  School  Chair  with  Adjustable 
Lumbo-Sacral  Support,  Favoring  Correct  Posture. 

from  the  desk,  thus  allowing  freedom  of  movement  at 
the  hips,  and  permitting  the  necessary  adjustment  of 
distance  from  the  desk  for  various  kinds  of  work. 

"  2.  The  back  of  the  chair  is  straight  and  very  nearly 


DEFORMITIES    OF    THE    SPINE 


141 


at  right  angles  to  the  seat,  thus  holding  the  sitter's  back 
erect. 

"  3.  The  back  of  the  chair  is  open  at  the  base,  thus 
allowing  the  base  of  the  spine  to  be  pushed  well  back 
and  giving  it  perfect  freedom,  which  is  necessary. 


Fig.  59.  Fig.  60. 

Figs.  59  and  60. — Correct  Postures  at  Desk;  Seeking  Chair. 

"  4.  The  back  of  the  chair  has  two  points  of  support, 
a  fixed  upper  slat  and  an  adjustable  lower  slat,  which 
by  means  of  its  adjustability  may  be  made  to  support 
any  sitter's  back  at  the  proper  point. 

"  5.  The  back  of  the  chair  is  both  narrow  and  straight. 
This  allows  the  shoulders  to  be  square  and  avoids  all 
rounding  of  the  shoulders  necessarily  caused  by  a  curved 
chair  back, 

"  6.  The  chair  is  made  of  different  heights  from  the 
floor  to  fit  all  sizes  of  peoi^le."     (Sebring.) 


142    DEFOEMITIES    OF    NECK   AND    TRUNK 

Actual  trial  in  the  schoolroom  has  shown  that  the 
pupils  sit  better  and  are  more  comfortable  on  the  Sebring 
chair  than  on  the  usual  school  furniture.  If  desired,  the 
Sebring  seat  may  be  attached  to  an  adjustable  base  fixed 
to  the  floor. 

Anything  that  weakens  general  vigor  and  interferes 
with  nutrition  will  evidently  decrease  the  resistance  of 
the  tissues  and  render  the  child  more  vulnerable  to  the 
unfavorable  influences  to  which  all  children  in  civilized 
life  are  inevitably  exposed.  One  such  influence  is  a  pam- 
pered or  hothouse  life;  another  is  overstudy;  another 
is  too  much  time  devoted  outside  of  school  to  things  in 
themselves  wearying,  like  violin  or  piano  practice,  than 
which  there  are  few  things  more  depressing.  Voice  cul- 
ture, with  its  associated  breathing  movements  and  insist- 
ence on  good  posture,  is,  on  the  other  hand,  beneficial. 
In  another  class  it  is  overwork,  underfeeding,  and  the 
violation  of  the  more  obvious  hygienic  laws. 

That  a  certain  predisposition  toward  scoliosis  exists 
in  many  children  is  shown  by  the  fact  that  some  observ- 
ers have  found  scoliosis  in  the  family  in  fully  one  quar- 
ter of  the  cases.  Slight  or  moderate  scoliosis  is  often 
combined  with  round  back.  Adenoids,  hypertrophied 
tonsils,  and  nasal  obstruction  are  present  in  some  cases 
of  scoliosis. 

The  PATHOLOGICAL  ANATOMY  of  scoliosis  Tcvcals  the 
adaptation  of  the  spinal  column  and  thorax  to  the  ab- 
normal posture.  The  spine  as  a  whole  is  bent  to  the 
side  in  one  or  more  regions,  twisted  and  skewed.  The 
column  of  bodies  is  more  bent  than  the  column  of  arches 
and  processes;  this  is  the  result  of  rotation  or  twisting. 


DEFORMITIES    OF    THE    SPINE 


143 


For  this   reason  the  scoliotic  column,  viewed  from  in 
front,  shows  much  more  deformity  than  from  behind. 


Fig.  61. — -Scoliotic  Spine;  Secondary  Changes  in  Vertebra  and  Ribs. 
(Author's  specimen.) 


In  other  words,  the  deformity  is  much  worse  than  it 
appears.    The  ribs  being  tied  to  the  sternum,  this  rota- 


144    DEFORMITIES    OF    NECK   AND    TRUNK 

tion  toward  the  convexity  bends  the  ribs  at  their  angles, 
causing  bulging  on  the  side  of  the  convexity,  and  flattens 
or  straightens  them  on  the  concave  side.  This  results 
in  a  large  increase  of  one  diagonal  of  the  thorax  and  a 
corresponding  decrease  of  the  other.  The  ribs  on  the 
convexity  are  broadened,  those  on  the  concavity  are  nar- 
rowed (Fig.  61).  False  joints  result  from  the  crowding 
together  of  the  spinal  ends  of  the  ribs.  The  obvious 
effect  of  these  changes  is  a  decrease  in  the  height,  capac- 
ity, and  mobility  of  the  thorax,  and  certain  characteristic 
deformities.  The  lateral  tilt  and  bulging  ribs  cause  ele- 
vation and  prominence  of  the  scapula  (high  shoulder) 
on  the  convex  side  of  the  thorax,  and  the  contrary  effect 
is  produced  on  the  concave  side.  There  are  correspond- 
ing changes  in  the  front  of  the  thorax.  Rotation  in  the 
lumbar  region  causes  effacement  of  the  waist  on  the  side 
of  the  convexity  and  increased  hollowing  above  the  iliac 
crest  on  the  concave  side  (high  hip) ;  this  may  be  neu- 
tralized by  the  shifting  of  the  body  to  the  side  opposite 
to  the  rotation. 

Each  individual  vertebral  body  participating  in  the 
curvature  is  also  deformed.  If  near  the  center  of  the 
curve  it  becomes  wedge-shaped,  with  the  narrow  side 
toward  the  concavity;  it  also  becomes  skewed  and 
changed  in  its  internal  architecture.  In  the  simple  pos- 
ture cases  there  is  no  evidence  of  disease.  In  the  forms 
of  scoliosis  secondary  to  bone  disease,  the  changes  char- 
acteristic of  the  disease  in  question  may  also  be  found  in 
the  vertebrae. 

An  early  diagnosis  is  of  the  greatest  importance,  and 
should  be  made  by  the  family  doctor.    It  is  only  in  the 


DEFORMITIES    OF    THE    SPINE  145 

functional  cases,  still  free  from  rigidity  and  fixed  rota- 
tion, that  perfect  results  from  treatment  may  be  looked 
for.  Every  postural  anomaly  pointed  out  by  the  parents, 
or  noticed  by  the  physician,  should  be  critically  examined 
and  conscientiously  rectified.  It  is  unfortunately  true 
that  most  cases  are  discovered  by  the  mother  or  dress- 
maker, after  fixed  deformity  makes  a  perfect  restoration 
impossible,  though  much  may  still  be  done  to  ameliorate 
the  condition.  A  rigid  examination  of  growing  children 
for  faults  of  posture  should  be  made  at  least  once  a 
year  by  the  family  physician. 

For  the  examhstation  all  clothing  should  be  removed 
from  the  hips  up,  and  the  waist  bands  loosened  and 
pinned  at  the  level  of  the  trochanters;  the  shoes  should 
also  be  removed.  The  patient  so  prepared  stands  with 
the  back  to  the  examiner,  who  notes  the  posture  of  the 
head,  the  outlines  and  levels  of  the  shoulders  and  hips, 
the  side  lines  of  the  trunk,  and  the  line  of  the  spinous 
processes,  which  may  also  be  palpated  (Fig.  62).  The 
flat  hands  are  placed  over  the  iliac  crests  to  ascertain 
if  they  are  on  the  same  level,  care  being  taken  to  have 
the  patient  stand  with  straight  legs  and  equally  on  both 
feet.  The  patient  is  then  instructed  to  bend  forward, 
allowing  the  head  and  arms  to  hang  down.  This  causes 
the  scapulae  to  slide  away  from  the  spine,  exposing  the 
angles  of  the  ribs,  and  any  posterior  projection  due  to 
rotation  will  be  apparent  (Fig.  64).  The  lateral  mobil- 
ity of  the  spine  may  then  be  tested,  after  which  the 
posture  may  be  viewed  from  the  side,  and  the  front  of 
the  thorax  may  be  inspected  for  costal  or  thoracic  asym- 
metry.    The  feet   should  be  examined  for  flatness  or 


146    DEFOEMITIES    OF    NECK   AND    TRUNK 

weakness  and  shortening  of  the  heel  cords,  and  the  knees 
for  knock-knees,  and  if  pelvic  obliquity  is  suspected  the 


Fig.  62. — Right  Dorsal,  Left  Lum- 
bar Scoliosis;  Girl  op  Twelve. 


Fig.  63. — Same,  with  Strip  of  Ad- 
hesive Applied  for  Tracing, 
AND  Plumb  Line. 


length  of  the  legs  should  he  measured  in  recumbency 
from  the  anterior  superior  spine  of  the  ilium  to  the  tip 
of  the  internal  malleolus. 


V 


DEFORMITIES    OF    THE    SPINE 


147 


For  EECORD  the  weight,  height,  and  chest  girths  in  ex- 
piration and  inspiration  should  be  taken,  and  a  tracing 
of  the  spinous  processes  marked  in  pencil  on  a  strip  of 
zinc  oxid  adhesive  j^laster 
two  inches  wide  and  eigh- 
teen inches  long,  which  has 
been  stuck  to  the  back  from 
the  seventh  cervical  to  the 
sacrum  ( Fig.  63 ) .  The  level 
of  the  lower  angle  of  each 
scapula  and  the  true  ver- 
tical at  the  gluteal  notch 
should  also  be  marked  on 
the  strip,  which  should  be 
dated  and  pasted  in  a  book 
with  the  history  of  the 
patient.  To  indicate  the 
rotation  the  transverse 
contour  of  the  joosterior 
half  of  the  thorax  may 
be  taken  in  the  forward 
stooping  position,  with  a 
lead  tape  at  the  point  of 
greatest  deformity  (Eoth), 
and  traced  off  into  the  his- 
tory book.  A  photograph 
of  the  back  to  scale  is  also 
desirable  for  purposes  of 
record. 

Classification  of  Curves.- 
classified  according  to  the  number  and  location  of  the 


Fig.  64. — Same,  Dorsal  Rotation 
TO  Right  Unmasked  by  For- 
ward Stooping. 


-Lateral  curvature  may  be 


148    DEFORMITIES    OF    NECK   AND    TRUNK 

curves  into  simple  and  compound.  The  curves  are  named 
from  the  direction  of  the  convexity.  The  simple  or  C 
curves  may  affect  the  whole  spine,  or  its  upper  or  Ijwer 


Fig.    65.  —  Left    Total    Scoliosis;         Fig.    66.  —  Self-Correction    by 
Girl  of  Seven.  Right  Upward,  Left  Down- 

ward Stretch. 

part  only,  and  the  convexity  may  be  turned  to  the  right 
or  to  the  left.  The  simple  curves  to  the  left  are  com- 
mon, to  the  right  much  rarer.     The  left  total  scoliosis, 


DEFORMITIES    OF    THE    SPINE  149 

or  C  curve,  is  the  commonest  of  all  forms  in  schools  and 
gymnasia  (Figs.  65  and  66).  In  this  form  the  left  shoul- 
der is  high,  the  right  hip  prominent,  and  the  trunk  may 
be  carried  to  the  left  so  that  the  left  arm  swings  free. 
The  angles  of  the  ribs  are  more  prominent  on  the  left 
side  from  the  rotation,  and  this  fullness  is  more  ap- 
parent when  the  patient  bends  forward  with  the  arms 
hanging.  In  merely  functional  cases,  however,  the  full- 
ness may  be  on  the  right  or  concave  side. 

In  left  lumbar  scoliosis  the  picture  is  much  the  same 
except  that  the  curve  only  involves  the  spine  below  the 
scapulae,  and  in  the  early  stages  the  shoulders  are  level. 
There  is  bulging  in  the  left  lumbar  region,  flatness  in 
the  right.  Both  the  left  total  and  left  lumbar  scoliosis 
have  a  tendency  to  pass  into  the  right  dorsal,  left  lumbar 
compound  or  I  curve  by  the  addition  of  a  secondary 
or  compensating  curve  convex  to  the  right  in  the  dorsal 
region. 

This  right  dorsal  left  lumbar  ^  scoliosis  may  also 
be  formed  by  a  primary  right  dorsal  scoliosis  adding  a 
compensating  left  lumbar  curve.  These  compound  right 
dorsal  left  lumbar  curves  are  the  ones  most  frequently 
seen  in  special  practice,  and  are  sometimes  of  dorsal  and 
sometimes  of  lumbar  origin.  When  this  dorsal  curve  is 
primary  the  rotation  and  deformity  are  usually  much 
more  disfiguring,  as  the  thorax  and  shoulders  are  more 
distorted  (Figs.  67  and  68).  In  the  right  dorsal  (pri- 
mary) left  lumbar  compound  scoliosis,  of  fixed  type,  the 
right  shoulder  is  high  and  prominent,  the  left  shoulder 
low,  the  left  hip  prominent,  and  the  right  effaced;  the 
spinous  processes  form  an"   ^    curve,  of  which  the  dorsal 


150    DEFORMITIES    OF    NECK   AND    TRUNK 

curve  is  the  larger.     There  is  marked  backward  projec- 
tion of  the  ribs  on  the  right  side,  more  evident  in  the 


Fig.  67. — Right  Dorsal  Scoliosis;  Girl  of  Fifteen. 

stooping  posture,  while  the  ribs  under  the  left  scapula 
are  flattened.  The  left  side  of  the  lumbar  region  is  full, 
but  less  so  than  in  primary  left  lumbar  curvature.  The 
trunk  is  shifted  to  the  right.  The  left  breast  and  left 
side  of  the  thorax  in  front  are  prominent. 


DEFORMITIES    OF    THE    SPINE 


151 


When  the  posterior  projection  is  marked  the  deform- 
ity is  called  a  kypho-scoliosis  (Figs.  69  and  70). 

In  certain  cases  secondary  curves  are  formed  both 
above  and  below  the  primary  dorsal  curve,  giving  a 
^  -shaped  curve. 


Fig.  68. — Self-Correction  by  Side  Pressure. 


The   total  curves   to   the  right  and  the   left  dorsal 
right    lumbar    curves    are    the    reverse    of    those    de- 


152    DEFORMITIES   OF   NECK   AND   TEUNK 

scribed,   and  of  much,  less  frequent  occurrence   (Figs. 
71  and  72). 

Besides  the  curvatures  themselves  and  the  accom- 
panying rotation  and  secondary  changes  in  the  thorax 


Fig.  69. — Kypho-Scoliosis  to 
Right  Dorsal. 


Fig.  70. — Same;  Three-quartee 
View. 


and  ribs,  hips,  and  shoulders,  with  the  peculiarities  of 
posture  and  limitation  of  motion  imposed  by  fixed  curves, 
there  are  few  symptoms.    Pain,  backache,  or  tenderness 


DEFORMITIES.  OF    THE    SPINE  153 

are  imusual,  except  in  neurotics  and  in  the  extreme  dis- 
tortions of  adolescents  and  adults,  when  there  may  be 
pain  from  abnormal  contact  of  bone  or  from  nerve  com- 


FiG.  71. — Cervico-Dorsal  Scoliosis  to  the  Left. 

pression.  There  may  be  considerable  displacement  and 
compression  of  thoracic  and  abdominal  viscera,  but  the 
tendency  to  pulmonary  disease  does  not  seem  to  be  in- 

12 


154    DEFORMITIES    OF    NECK   AND    TRUNK 

creased,  and  the  harmful  effect  is  shown  in  severe  cases 
rather  in  a  delicate  or  dwarfed  physique,  a  careworn 
facies,  and  lack  of  endurance  than  by  local  visceral  dis- 


FiG.  72. — Keel-shaped  Projection  of  Left  Ribs  Due  to  Rotation 
Uniiasked  by  Forward  Bending.     Same  patient  sho-mi  in  Fig.  71. 

turbance.    Shortness  of  1)reath  and  rapid  pulse  are  com- 
mon in  severe  cases. 

The  DIAGNOSIS  is  usually  not  difficult,  except  in  very 
early  cases.  When  a  lateral  bending  or  inclination  is 
found  it  is  vitally  important  to  determine  whether  it  is 
uncomplicated  or  is  secondary  to  some  pathological 
cause,  as  the  treatment  is  very  different.  In  particular, 
those  cases  due   to  congenital  malformation,  paralytic 


DEFORMITIES    OF    THE    SPINE  155 

conditions,  and  bone  disease  should  be  strictly  differen- 
tiated from  the  uncomplicated  or  postural  cases,  and  in 
these  one  should  endeavor  to  distinguish  the  functional 
from  the  structural.  It  is  specially  to  be  remembered 
that  lateral  deviation  or  shifting  at  the  point  of  disease 
is  very  common  in  early  spondylitis  (Fig.  90) ;  also  that 
in  some  advanced  cases  of  scoliosis  the  posterior  bosse 
may  be  so  extreme  as  to  resemble  the  deformity  of  old 
Pott's  disease  when  the  patient  is  clothed.  Examination, 
however,  will  always  show  that  in  scoliosis  the  deformity 
is  due  to  the  projection  of  the  ribs  on  one  side.  The  sub- 
ject is  still  further  complicated  by  the  not  infrequent 
occurrence  of  scoliosis  in  the  late  stages  of  Pott's  dis- 
ease. 

The  PROGNOSIS  of  postural  lateral  curvature  is  very 
good  under  proper  management  in  the  early  (function- 
al) stage,  before  bony  changes  have  taken  place;  and  in 
structural  curves  of  moderate  degree  the  results  of  treat- 
ment are  very  satisfactory.  It  must  be  admitted,  how- 
ever, that  neglected  and  extreme  cases  present  one  of  the 
most  difficult  problems  in  orthopedic  surgery,  and  that 
the  results  of  treatment  are  only  palliative.  There  are 
few  cases,  however,  where  the  vigor,  strength,  and  car- 
riage of  the  patient  cannot  be  improved  by  persistent 
treatment.  Light  cases  with  little  or  no  tendency  to  in- 
crease, of  which  there  are  many,  may  easily  be  made 
too  much  of;  such  cases  are  in  no  way  serious.  On  the 
other  hand,  many  cases  are  made  too  little  of,  and  neg- 
lected until  a  hideous  deformity  is  fastened  on  the  patient 
for  life.  One  cannot  always  distinguish  the  curvatures 
that  are  likely  to  increase  from  those  that  will  probably 


156    DEFOEMITIES   OF   NECK   AND   TRUNK 

remain  stationary;  therefore,  all  should  be  kept  under 
observation.  It  is  to  be  remembered  that  the  curves 
beginning  in  the  dorsal  region,  and  showing  a  great  deal 
of  rib  deformity  and  posterior  curvature,  are  usually 
serious.  Also  that  once  the  frame  is  consolidated,  after 
the  early  twenties,  progress  of  the  deformity  is  not  to 
be  feared,  except  in  unusually  bad  cases,  after  exhaust- 
ing diseases,  during  and  after  pregnancy,  and  in  old  age. 

The    TREATMENT    OF    FUNCTIONAL    SCOLIOSIS    COUSists    iu 

invigoration  and  postural  education,  to  the  end  that  the 
patient  may  acquire  the  sense  of  correct  posture  and 
that  he  may  have  the  desire  and  the  strength  to  assume 
correct  postures  habitually.  In  the  case  of  adolescent 
girls,  the  appeal  to  a  proper  pride  is  seldom  without 
effect.  The  regulation  of  activities  and  the  elimination 
of  detrimental  elements  is  much  the  same  as  in  round 
back.  Of  importance  is  the  matter  of  seats  and  desks, 
and  of  reading,  writing,  and  other  sitting  postures;  the 
mode  of  clothing  support ;  the  condition  of  the  eyes,  ears, 
and  throat;  the  question  of  standing  postures  and  pelvic 
obliquity ;  and  the  matter  of  overwork  and  persistent  fa- 
tigue. It  will  often  be  wise  to  sketch  a  daily  programme, 
with  stated  times  for  work,  play,  and  rest.  It  may  be 
necessary  to  lighten  or  suspend  school  work,  abolish 
piano  and  violin  practice,  and  enforce  regular  hours, 
A  half  hour  to  an  hour  of  rest  in  recumbency  early  in 
the  afternoon  will  often  be  very  beneficial,  and  ten  hours' 
sleep  should  be  insisted  on.  Open-air  sports,  if  not  one- 
sided, are  beneficial;  swimming  (breast  stroke)  is  the 
best,  cross-saddle  riding  in  good  posture,  running,  and 
climbing  are  good;  voice  culture  is  excellent.     Tennis, 


DEFORMITIES    OF    THE    SPINE  157 

golf,  and  side-saddle  riding  are  often  objectionable.  In 
connection  with  posture  training  special  gymnastics,  con- 
sisting mainly  of  trunk  movements,  both  standing  and 
recumbent,  balance  movements,  stretching  movements, 
suspension  movements,  deep  breathing,  and  a  certain 
number  of  corrective  exercises,  should  be  given,  prefera- 
bly by  an  exjoert,  two  or  three  times  a  week  for  several 
months ;  and  at  the  same  time,  and  afterwards,  certain  ex- 
ercises should  be  practiced  at  home.  It  is  necessary  that 
the  whole  body,  and  especially  weak  parts,  like  the  feet, 
waist,  chest,  and  neck,  be  harmoniously  and  adequately 
developed.  The  use  of  the  vibrator  after  each  session 
is  refreshing,  and  stimulating  to  the  spinal  muscles.  The 
work  should  progress  from  easy  to  difficult,  but  should 
be  kept  simple.  The  majority  of  the  exercises  will  be 
symmetrical  or  alternating,  according  to  the  best  modern 
practice.  The  exercises  should  be  done  slowly  and  ex- 
actly, with  a  pause  at  the  final  pose,  and  each  exercise 
repeated  six  to  twelve  times.  In  simple  and  lumbar 
curves  it  is  often  useful  to  sleep  on  the  side  of  the 
high  hip. 

Jackets  or  artificial  supports  will  not  usually  be  re- 
quired for  the  purely  functional  cases,  but  numbers  of 
the  moderately  resistant  cases  will  be  much  improved 
by  the  application  of  a  light  supporting  corset.  The  form 
lately  used  by  the  writer,  and  giving  much  satisfaction, 
is  a  corset-brace,  made  of  strong  coutil  and  in  appearance 
much  like  a  woman's  long  corset ;  this  is  carefully  fitted 
to  the  patient  from  the  axillae  to  the  trochanters,  and  re- 
enforced  by  three  pairs  of  light  steel  bars  shaped  to  pro- 
duce the  pressure  desired  behind  and  at  the  sides;  the 


158    DEFORMITIES    OF    NECK    AND    TRUNK 

corset  is  provided  with  broad  shoulder  straps,  starting 
under  the  axillae,  passing  over  the  shoulders,  crossing  be- 
hind the  scapulae,  and  buckled  low  down  in  front  (Fig.  73). 


Fig.  73. — The  Van  Winkle  Corset-Brace  Adjusted  in  a  Marked  Case 
OF  Scoliosis,  Low  Dorsal  to  Right,  Lumbar  to  Left. 

Structural  scoliosis  will  require  much  the  same  treat- 
ment in  the  lighter  grades,  but  with  more  emphasis  on 
corrective  work;  in  the  severe  forms,  the  stretching  of 
retracted  tissues,  mobilization  of  stiffened  parts,  and  me- 
chanical retention  of  correction  gained  may  be  impor- 


DEFORMITIES    OF    THE    SPINE 


159 


tant.  These  objects  are  accomplished  by  gymnastics, 
with  and  without  apparatus,  stretching,  forcible  correc- 
tion, and  spinal  supports. 

The  stretching  may  be  done  by  lateral  suspension, 
and  by  pressure  boards  or  frames.  Suspension  from 
the  hands  with  side  pressure,  as  in  the  stretcher  (C. 
F.  Taylor)  is  one  of 
the  simplest  and  most 
effective  means  (Fig. 
74).  Stretching  over 
the  padded  bar  or 
end  of  couch  is  simi- 
lar in  effect.  Side 
pressure  in  the  hori- 
zontal kneeling  pos- 
ture, as  in  Lovett's 
pressure  board,  is 
also  excellent  (Fig. 
75).  Mobilization  may 
also  be  effected  by 
heavy  dumb-bell  and 
bar  work  (Tesch- 
ner),  and  by  the 
various  special  cor- 
rective postures  and 
exercises. 

Coincidently    with 
mobilization  and  cor- 
rection   the    muscles 
are  trained  and  strengthened  to  hold  the  spine  in  the 
improved  posture.     Many  of  these  cases  will  require 


Fig.  74. — C.  F.  Taylor's  Lateral  Suspen- 
sion Apparatus  for  the  Correction 
OP  Scoliosis. 


160    DEFOEMITIES    OF    NECK    AND    TRUNK 

corrective  corsets  or  jackets,  which  may  be  applied 
directly  to  the  patient  or  made  over  a  corrected  cast.  A 
good  method,  when  the  plaster  corset  is  directly  applied, 


Fig.  75. — Lovett's  Stretching-Board  with  Surcingles. 

is  to  fill  out  the  hollow  side  with  cotton,  which  is  removed 
after  the  corset  is  finished,  to  allow  room  for  expan- 
sion, and  to  increase  the  pressure  over  the  convexity  of 
the  curve  by  attaching  felt  pads  to  the  inside  of  corre- 
sponding parts  of  the  corset  (Fig.  76).  The  same  result 
can  be  accomplished  by  corrections  to  the  plaster  torso 
taken  from  the  jacket  as  a  negative.  A  plaster,  paper, 
leather,  or  aluminium  corset  may  be  made  over  this  cor- 
rected torso.  Most  braces  bought  in  the  shops  are  worth- 
less, and  many  are  injurious.  When  corsets  are  used, 
they  are  intended  to  keep  the  gain  made  by  the  exercises 
and  manipulations.  They  should  be  renewed  or  cor- 
rected every  few  weeks  or  months,  and  the  exercises 


DEFORMITIES    OF    THE    SPINE 


161 


should  be  continually  practiced.  The  use  of  braces  and 
corsets  without  gymnastics  is  usually  injurious,  and  the 
use  of  gymnastics  alone  in  severe  cases  is  usually  fruit- 
less.   The  application  of  great  force,  followed  by  reten- 


FlG.    76. — rLASTEK-OF-PARIS   CORSET. 

tive  jackets,  is  not  free  from  danger,  and  is  of  question- 
able value  except  in  rare  instances  in  the  hands  of 
experts. 


162    DEFORMITIES    OF    NECK    AND    TRUNK 

The  treatment  of  structural  cases  must  be  under- 
taken seriously  and  systematically,  and  kept  up  for  a 
long  period  in  order  to  give  results.  It  is  not  infre- 
quently necessary  to  remove  the  child  from  school  for  a 
time.  Serious  gymnastic  work,  in  addition  to  school  du- 
ties, will  frequently  do  more  harm  than  good.  The  kind 
and  amount  of  gymnastics  and  the  regulation  of  the  pa- 
tient's life  will  call  for  the  exercise  of  great  judgment 
and  good  sense.  Even  in  bad  cases,  however,  the  general 
health  may  nearly  always  be  built  up,  strength  and  vigor 
increased,  the  posture  improved,  and  the  deformity  kept 
from  increasing.  In  extreme  cases  the  curvature  may 
be  obscured  by  compensation  above  and  below,  and  the 
carriage  may  be  improved  by  training  the  patient  to 
maintain  his  best  postures. 

II.  The  curvatures  due  to  the  pelvic  obliquity  caused 
by  a  short  leg  are  rarely  serious.  Even  in  the  excessive 
deformities  due  to  coxitis,  unilateral  congenital  disloca- 
tion, and  other  conditions  characterized  by  a  short  leg, 
fixed  curves  with  rotation  are  rare.  Shortening  of  a 
quarter  to  half  an  inch  without  assignable  cause  is  not 
very  rare,  and  frequently  passes  unnoticed  by  the  pa- 
tient. It  very  rarely  causes  any  permanent  deformity 
of  the  spine.  If  the  patient  is  a  child,  the  difference 
should  be  equalized  by  adding  a  cork  sole  to  the  shoe  of 
the  short  leg;  if  an  adult,  differences  of  a  fraction  of 
an  inch  are  usually  perfectly  harmless. 

III.  Scoliosis  due  to  contraction  of  the  pleural  cavity  fol- 
lowing empyema  may  be  of  severe  grade.  If,  however, 
the  lung  regains  its  expansion,  as  sometimes  happens, 
the  spinal  deformity  largely  disappears.    The  treatment 


DEFORMITIES    OF    THE    SPINE 


163 


in  recent  cases  should  be  directed  to  expanding  the  col- 
lapsed lung  by  deep-breathing  exercises,  which  may  be 
made  unilateral.  It  is  important  that  adhesions  between 
the  parietal  and  pulmonary  pleura  should  be  thoroughly 
separated  in  order  to  allow  the  lung  to  expand  at  the 


Fig.  77.  Fig.  78. 

Figs.  77-78. — Collapse  of  Right  Lung  and  Secondary  Scoliosis  Fol- 
lowing Empyema  at  the  Age  of  Five.  Portions  of  two  ribs  were 
excised;  the  opening  never  closed  and  after  eighteen  years  is  still  dis- 
charging.    Patient  is  now  twenty-three. 

time  the  chest  is  evacuated  (Lloyd).  In  the  old  and 
resistant  cases  the  usual  treatment  for  rigid  scoliosis 
may  mitigate,  but  cannot  correct,  the  condition  (Figs. 
77  and  78). 


164    DEFORMITIES    OF    NECK    AND    TRUNK 

IV.  Scoliosis  is  a  rather  frequent  sequela  of  acute 
poliomyelitis.  It  does  not  develoj)  from  a  ^liort  or  weak- 
ened leg,  biit  only  from  asymmetrical  paralysis  of  one 
or  more  of  the  back  or  abdominal  muscles  (Fig.  31). 
When  this  condition  exists  the  deformity  may  be  aggra- 
vated by  a  short  or  deformed  leg.  Scoliosis  and  spinal 
weakness  make  the  treatment  of  the  locomotor  disability 
much  more  difficult.  It  is  of  the  greatest  importance  that 
locomotion  be  improved  or  restored  by  the  correction  of 
deformities  of  the  limbs,  and  by  the  use  of  supporting 
splints,  and  a  cork  sole  under  the  short  leg.  When  sco- 
liosis or  spinal  weakness  exists  to  a  disabling  degree, 
spinal  supports  in  the  form  of  corsets,  or,  better,  a  steel 
and  leather  apparatus  joined  to  the  pelvic  band  of  the 
leg  brace,  may  be  of  use  in  keeping  the  patient  erect  and 
helping  him  to  get  about.  The  spinal  deformity,  how- 
ever, usually  persists.  Scoliosis  may  complicate  sev- 
eral other  diseases  of  the  nerves,  and  it  should  not 
be  forgotten  that  an  hysterical  form  exists  which  is 
usually  curable  by  appropriate  tonic  and  suggestive 
treatment. 

V.  Lateral  curvature  due  to  disease  in  or  near  the  spinal 
column  is  best  treated  by  treating  the  primary  disease, 
be  it  tuberculosis  of  the  spine  (Fig.  90),  sacro-iliac  dis- 
ease, or  some  other  affection.  When  due  to  general 
involvement  of  the  spine  in  a  slow  asymmetrical  anky- 
losing process  in  adults,  as  in  osteoarthritis,  ostitis  de- 
formans, and  the  like,  spinal  support  by  means  of  jackets 
and  corsets  may  be  of  great  value,  not  only  giving  the 
patient  great  relief,  but  favoring  the  termination  of  the 
process. 


DEFORMITIES-  OF    THE    SPINE  165 

Strengthening,  Postural,  and  Corrective  Exercises  Use- 
ful in  Most  Forms  of  Scoliosis 

Posture. — The  chest  being-  held  high,  the  chin  and  ab- 
domen somewhat  retracted,  and  the  feet  pointing  forward 
(Fig.  42),  the  correct  forward  inclination,  and  poise  on 
the  balls  of  the  feet  may  be  acquired  by  (1)  swinging  the 
straight  arms  strongly  and  briskly  forward  and  back- 
ward;  (2)  walking  backward  and  stopping  suddenly. 

Spinal  correction  is  obtained  by  tilting  and  turning 
the  head  and  shoulder  girdle,  which  control  the  upper 
spine;  by  tilting  and  turning  the  pelvis,  which  controls 
the  lower  spine;  by  side  pressure,  and  by  other  cor- 
rective movements,  all  of  which  are  more  effective  in 
horizontal  posture  and  in  suspension,  since  gravity  is 
then  eliminated  or  made  to  assist  in  the  correction. 

In  vertical  free  exercises  the  effect  may  often  be  in- 
tensified by  fixing  the  pelvis,  which  is  done  to  a  certain 
extent  in  sitting.  Trunk  rotation  causes  a  dorsal  curve 
in  the  opposite  direction,  and  is  raised  in  trunk  flexion, 
lowered  in  trunk  extension.  In  hyperextension  the  dor- 
sal spine  is  locked  for  side  flexion  (Lovett). 

Corrective  and  asymmetrical  postures  and  exercises 
are  very  far-reaching  in  their  effects,  and  not  easily  lo- 
calized and  controlled;  moreover,  the  effect  on  the  sco- 
liotic spine  cannot  always  be  predicted  from  the  effect 
on  the  normal  spine.  It  is  therefore  wise  to  rely  mainly 
on  symmetrical,  nearly  symmetrical,  and  alternating  ex- 
ercises for  the  basis  of  the  work,  adding  only  such  asym- 
metrical movements  from  time  to  time  as  prove  to  be 
really  corrective.     Symmetrical  exercises,  properly  se- 


166    DEFORMITIES    OF    NECK    AND    TRUNK 

lected  and  executed,  have  not  only  a  strengthening  but 
also  a  corrective  effect,  since  their  general  tendency  is 
to  bring  the  spine  toward  the  median  line.  Persons  with 
only  a  superficial  knowledge  of  scoliosis  and  of  remedial 
exercises  are  quite  as  apt  to  do  harm  as  good  by  attempt- 
ing corrective  work.  The  patient  should  be  drilled  with 
the  back  bare,  in  order  to  observe  the  effect  of  the  dif- 
ferent exercises.  This  is  easily  done  by  removing  the 
clothing  down  to  the  hips,  and  covering  the  front  of  the 
chest,  if  desired,  by  a  small  apron  or  shield  tied  around 
the  neck. 

Breathing  exercises,  balance  movements,  trunk  flex- 
ions, horizontal  exercises,  and  exercises  in  suspension, 
graduated  according  to  the  strength  of  the  patient  and 
to  the  effect  observed,  may  be  used  for  general  develop- 
ment, control,  invigoration,  and  mobilization,  as  in  the 
treatment  of  round  back.  The  horizontal  exercises  pre- 
scribed for  round  back  (Numbers  1  to  5,  page  127)  make 
a  good  series  to  begin  on  and  for  home  practice  (on  the 
floor).  Several  may  be  made  corrective  by  slight  modi- 
fication. For  instance,  with  a  curve  to  the  left,  if  in 
prone  leg  lifting  the  left  leg  is  slightly  abducted  and 
lifted  high,  the  lower  spine  will  bend  to  the  right.  Also 
in  trunk  extension  with  hands  clasped  behind,  if  the 
hands  are  carried  to  the  side  of  the  concavity,  the  move- 
ment will  be  corrective.  The  term  corrective  should  be 
understood  in  the  sense  of  momentary  improvement  in 
posture;  if  the  exercises  do  not  result  in  a  better  ha- 
bitual posture,  either  aided  or  unaided,  the  correction 
amounts  only  to  a  mobilization. 

In  the  following  prescriptions  of  corrective  exercises 


DEFORMITIES    OF    THE    SPINE  167 

each  exercise  is  first  named;  next  the  posture  is  given; 
lastly  the  movement  is  described.  It  is  understood  that 
each  movement  is  to  be  executed  slowly,  exactly,  and 
with  force,  holding  the  final  pose  a  moment ;  the  exercise 
is  completed  by  a  return  to  the  original  posture,  and  is 
to  be  repeated  several  times.  I  am  specially  indebted  to 
the  descriptions  and  movements  in  Lovett's  excellent 
brochure  on  lateral  curvature. 

COKRECTIVE    EXERCISES    FOE    LEFT    LUMBAR    CURVES 

Standing. 

1.  Up-and-down  stretch.  Elbows  bent,  hands  in  front 
of  shoulders,  trunk  inclined  forward  from  hip-joints; 
stretch  right  arm  up,  left  down  (Fig.  66). 

2.  Hip  sinking  (Hoffa).  Hands  on  hips  (or  behind 
neck),  right  foot  placed  forward  and  outward  two  foot 
lengths;  with  forward  inclination  of  the  body,  rock  for- 
ward and  back  by  bending  the  right  knee  (Fig.  79). 

3.  Hip  sinking  from  stool.  Hands  on  hips;  stand  on 
left  leg  on  stool,  sink  right  leg. 

4.  Half  circle  to  side.  Arms  stretched  upward ;  swing 
arms  and  body  forward  and  to  the  left  and  upward  with 
a  circular  motion,  while  the  body  and  feet  turn  to  the 
left. 

Prone  lying. 

5.  Left  leg  raising.  Hands  under  chin;  raise  left  leg 
in  slight  abduction,  as  much  as  possible  (Fig.  49). 

Hanging  from  trapeze. 

6.  Feet  pressed  together;  carry  both  feet  to  the 
left. 


168    DEFORMITIES    OF    NECK   AND    TRUNK 

In  right  lumbar  curves  the  direction  of  the  movements 
is  reversed. 


COEEECTIVE    EXERCISES    FOR    LEFT    TOTAL    CURVES 

1.  Up-and-down  stretch  (Fig.  66). 

2.  Hip    sinking    (Hoffa),    with    left   hand    pressing 

against  side  and 
right  hand  clasping 
head. 

6.  With  right  side 
of  trapeze  raised, 
push  feet  to  left. 

7.  Partial  suspen- 
sion by  one  arm  with 
opposite  arm  and 
leg  locked.  Stand- 
ing on  right  leg  and 
holding  bar  with 
right  hand  extended 
above  head,  with 
left  thigh  flexed  and 
left  arm  passed  un- 
der left  knee,  flex 
right  knee. 

8.  Side  pressure 
with  side  bending 
(Lorenz).  Sitting 
or  standing,  the  left 
hand  presses  against 

Fig.  79. — -Self-Correction  for  Right  Dor-        fu^     ^{^q      while     the 
SAL  Left  Lumbar  Curve.     Left  shoulder 
is  elevated,  right  hip  depressed.  right  hand  claspS  the 


DEFORMITIES    OF    THE    SPINE 


169 


head;  press  left  hand  against  side  as  trunk  bends  to 
left  (Figs.  80  and  81). 

9.  Creeping  (Klapp),  hands,  knees,  and  toes  padded. 


f 

Pig.  80. — Side  Pressure, 


Fig.  81. — Side  Pressure  with 
Side  Bending;  the  Hand 
Should  Grasp  the  Head. 


(a)  Left  hand  and  knee  approximated,  right  hand 
and  foot  stretched  far  apart;  creep,  with  emphasis  on 
this  posture. 

13 


170    DEFORMITIES    OF    NECK   AND    TRUNK 

(b)  Creep  sideways  to  right  in  above  posture;  face 
looks  to  left  (Fig.  82). 

Reverse  these  exercises  for  right  total  curves. 


Fig.  82. — Klapp's  Creeping  Posture  for  Left  Total  Scoliosis. 
COEKECTIVE    EXERCISES    FOR    EIGHT    DORSAL    CURVES 

4.  Half  circle  to  side.  Half  circle  to  right.  (See  No. 
4,  page  167.) 

8.  Side  flexion  with  side  pressure  (Lorenz)  to  right 
(Fig.  68). 

10.  Left  chest  expansion.  Right  hand  presses  against 
right  side,  high  up ;  raise  left  arm,  droop  hand  over  head 
with  inspiration,  while  head  bends  and  turns  to  right  and 
right  hand  presses  hard  against  chest. 

11.  Side  flexion  with  hands  clasped  behind  (Miku- 
licz). Hands  clasped  behind,  elbows  straight;  bend  for- 
ward, energize  arms,  bring  scapulae  back,  and  half  turn 
trunk  to  right.  Particularly  indicated  when  a  rib  kyphos 
is  combined  with  the  dorsal  scoliosis  (Lovett). 


DEFORMITIES  OF    THE    SPINE  171 

Sitting. 

12.  Trunk  twisting.  Hands  behind  neck;  twist  trunk 
to  right  with  elevation  of  left  shoulder.  With  forward 
bending  the  effect  will  be  higher;  with  backward  bend- 
ing, lower. 

Trapeze. 

13.  Feet  on  ground;  bend  and  stretch  to  right. 

Creeping. 

9.  {a)  Right  hand  and  knee  approximated,  left  hand 
and  foot  stretched  far  apart ;  creep  sideways  to  left,  head 
to  right. 


Fig.  83. — Klapp's  Creeping  Posture  for  Left  Dorsal  Curve. 

(b)  In  same  posture,  rotate  trunk  till  left  arm  is 
above  head ;  straighten  left  leg  and  back  upward  beneath 
left  arm. 

Reverse  the  exercises  in  left  dorsal  curves  (Fig.  83). 

Cervical  curves  to  left. 

14.  Neck  side  bending.  Bend  and  turn  neck  to  the 
left. 


172    DEFOEMITIES    OF    NECK    AND    TRUNK 

15.  Passive  neck  tilting.  Grasping  top  of  head  with 
left  hand,  pull  it  over  to  the  left. 

16.  Inclined  head  nodding.  Head  tilted  to  left,  flex 
and  extend  neck. 

If  one  shoulder  is  high,  this  should  be  depressed  dur- 
ing the  neck  movement. 

Simple  curves  are  much  easier  to  control  than  com- 
pound ones;  in  the  latter  the  exercises  that  correct  one 
curve  often  increase  the  other.  In  simple  curves,  ap- 
proximating the  hip  and  shoulder  of  the  convex  side, 
which  inclines  the  shoulders  and  pelvis  in  opposite  di- 
rections, effects  an  improvement  in  posture.  In  S-curves 
the  shoulders  and  pelvis  must  both  be  inclined  to  the 
side  of  the  dorsal  convexity,  or  the  double  correction 
may  be  effected  by  side  pressure  or  by  suspension. 


CORRECTIVE     EXERCISES     FOR     RIGHT     DORSAL     LEFT     LUMBAJl 

CURVES 

Standing. 

17.  Trunk  bending  to  sides  with  hand  pressure  (Mi- 
kulicz). Eight  hand  presses  against  right  side  under 
shoulder-blade,  left  hand  presses  against  left  lumbar  re- 
gion; bend  trunk  slowly  to  right,  then  to  left.  Can  also 
be  done  sitting. 

18.  Self -correction  with  hip  sinking  (2  and  8).  Left 
hand  clasps  top  of  head,  right  hand  presses  against  right 
side,  right  foot  two  foot  lengths  forward  and  outward; 
sink  right  hip  by  bending  and  straightening  right  knee, 
and  at  the  same  time  press  right  hand  against  side. 

19.  Lunge.  Stand  with  face,  left  foot,  hand,  and 
shoulder  facing  the  left,  right  foot  pointing  forward; 


DEFORMITIES    OF    THE    SPINE  173 

advance  left  foot  one  yard  to  left  with  knee  bent,  and 
thrust  hand  forward  and  upward,  left  hand  downward 
and  backward  (Fig.  84).     The  lunge  may  also  be  done 


Fig.  84. — -Lunge  Pustuhe  for    I  Curve. 

with  the  left  hand  clasping  top  of  head,  and  right  hand 
pressing  against  the  right  side. 

The  lunge  and  modified  lunge  may  also  be  taken  sit- 
ting on  the  edge  of  a  stool. 

20.  Suspension   by   hands   from   trapeze.     Feet   to- 


174    DEFOEMITIES    OF   NECK   AND    TRUNK 

gether;  elevate  left  side  of  trapeze,  if  left  shoulder  is 
low;  place  feet  together  and  push  feet  to  left. 

Prone  kneeling 

With  side  pressure  in  pressure  board  or  pressure 
frame. 

In  left  dorsal  right  lumbar  curves  the  exercises  are 
reversed. 

Diseases  of  the  Spinal  Column 

Several  inflammatory  affections  of  the  spinal  column 
cause  local  softening,  necrosis,  or  ankylosis,  and  lead  to 
the  formation  of  a  bosse,  gibbus,  or  hump  by  the  sink- 
ing and  falling  forward  of  that  portion  of  the  trunk 
above  the  point  of  disease.  If  the  local  destruction  pro- 
gresses more  rapidly  on  one  side,  a  lateral  deformity 
may  occur. 

The  most  important  destructive  disease  of  the  spinal 
column,  and  one  of  the  most  important  orthopedic  affec- 
tions, is  spondylitis  tuberculosa,  or  Pott's  disease  of  the  spine, 
the  common  cause  of  humpback.  In  New  York  it  forms 
about  two  fifths  of  all  tuberculous  joint  affections. 

OccuEEENCE. — The  disease  may  occur  at  any  age,  but 
is  commonest  in  early  childhood ;  more  than  half  the  cases 
occur  under  six.  The  age  of  greatest  susceptibility  is 
the  third  year;  it  is  very  rare  under  six  months.  It 
occurs  oftenest  in  the  dorsal  region,  and  next  in  the  lum- 
bar; the  liability  of  the  cervical  region  is  considerably 
less.  Its  distribution  in  the  spine  seems  to  agree  with 
the  exposure  of  the  part  to  trauma.  There  is  often  a 
history  of  phthisis,  alcoholism,  or  chronic  ill  health  in 
the  parents,  and  occasionally  a  history  of  phthisis  in  the 


DEFORMITIES    OF    THE    SPINE  175 

same  apartment,  not  necessarily  in  a  member  of  the 
family.  There  is  often  a  history  of  a  fall  or  moderate 
injury,  which  may  serve  to  excite  or  to  localize  the  proc- 
ess when  the  proper  internal  conditions  exist.  The  dis- 
ease frequently  begins  after  measles,  whooping-cough, 
scarlet  fever,  and  other  acute  infectious  diseases.  The 
whole  system  is  profoundly  affected,  the  rate  of  growth 
is  lessened,  and  in  extreme  cases  the  body  is  poorly 
nourished  and  dwarfed.  There  is  not  much  tendency 
toward  serious  general  or  visceral  affections,  though 
this  occurs  in  a  small  percentage  of  the  cases,  usually  in 
the  form  of  general  tuberculosis  or  tuberculous  menin- 
gitis. Pulmonary  involvement  is  rather  rare  in  children, 
more  common  in  adults.  Occasionally  several  joints  are 
affected,  when  the  possibility  of  syphilis  should  always 
be  considered. 

Pathology. — This  disease  is  now  known  to  be  a  bone 
tuberculosis,  starting  in  the  cancellous  tissue  of  the  body 
of  a  vertebra,  and  spreading  by  extension  of  the  tuber- 
culous granulation  and  gravitation  of  necrotic  products 
to  the  intervertebral  discs,  to  the  bodies  of  the  adjacent 
vertebrae,  and  to  the  surrounding  parts.  The  vertebral 
arches  and  articular  processes  usually  escape.  The  dis- 
ease is  a  local  destructive  process  of  low  grade  and  long 
duration,  with  a  strong  tendency  to  recovery  by  expul- 
sion, absorption,  or  encapsulation  of  the  morbid  prod- 
ucts, and  the  cicatrization  or  ossification  of  the  damaged 
part.  The  disease  is  thought  to  be  secondary  to  a  tho- 
racic or  abdominal  tuberculous  adenitis  in  most  cases. 

The  tuberculous  granuloma  is  of  low  vitality,  and  as 
it  becomes  larger  by  encroaching  upon  resorbed  neigh- 


176    DEFORMITIES    OF    NECK    AND    TRUNK 


boring  tissues  it  often  breaks  down  at  the  center  with 
the  formation  of  a  cheesy  mass  or  of  sequestra.  If  the 
disease  is  not  arrested  the  bodies  of  one  or  more  verte- 
brae are  often  entirely 
destroyed.  If  the  pro- 
cess is  more  rapid  on 
one  side,  a  lateral  in- 
clination may  result 
in  addition  to  the 
posterior  projection, 
and  frequently  a  fluid 
(serum,  ichor)  con- 
taining flocculi  and 
necrotic  debris,  but 
not  true  pus,  may 
collect  near  the  focus 
and  find  its  way  along 
the  muscular  or  fas- 
cial planes  toward  the 
surface.  Such  cold  or 
gravitation  abscesses 
(ichor  pockets)  usual- 
ly cause  but  little  dis- 
turbance unless  they 
become  infected.  They 
may  point  in  the  lum- 
bar region,  or,  follow- 
ing along  the  jDsoas 
muscle,  may  cause  its 
contraction  and  appear  in  the  thigh  below  Poupart's  liga- 
ment (Fig.  85) .  Tuberculous  granulations  or  fluid  may  ex- 


l»4l 

^^Br    > 

Fig.  85. — Large  Psoas  Abscess  (Ichor 
Pocket)  from  Ltjiibo-sacral  Pott's 
Disease,  in  a  Girl  of  Seven. 


DEFORMITIES    OF    THE    SPINE 


177 


ert  pressure  on  the  cord  or  excite  a  spinal  pachymeningi- 
tis, causing  a  pressure  paraplegia.  No  matter  how  great 
the  deformity,  there  is  rarely  any  bony  pressure  on  the 
cord.  Owing  to  the  vertebral  erosion,  the  upper  segment 
of  the  spinal  column  slowly  sinks  forward  until  it  finds 
support,  which  may  not  occur  until  the  spine  is  doubled 
on  itself  and  the  lower  ribs  rest  within  the  pelvis  (Fig. 


Fig.  86. — Tuberculosis  op  the  Spine;  Early  Case  at  the  Left.  Note 
that  even  in  the  cases  of  extreme  deformity  the  caliber  of  the  spinal 
canal  is  not  constricted.     (Author's  specimens.) 


86).  The  buckling  of  the  spine  shortens  its  vertical  height, 
and  consequently  the  height  of  the  patient.  It  also  pro- 
duces secondary  deformities  of  the  chest,  such  as  a  form 
of  pigeon-breast,  and  cramps  the  thoracic  and  abdominal 
viscera.  More  or  less  ankylosis  of  the  involved  vertebrae 
finally  occurs  in  many  of  the  cases  that  recover,  but  synos- 
tosis is  later  and  less  extensive  than  is  usually  assumed. 
The  SYMPTOMS  of  Pott's  disease  are  usually  charac- 
teristic before  the  appearance  of  deformity.  One  of  the 
earliest  signs  is  a  certain  stiffness  and  awkwardness  of 


178    DEFORMITIES    OF    NECK    AND    TEUNK 

posture,  a  tendency  to  restrict  spinal  movements,  to 
avoid  strains  and  jars.  The  child  often  rests  his  chin 
on  his  hands  or  his  elbows  on  the  furniture,  and  avoids 
play  and  activity.  The  affected  part  of  the  spine  resists 
passive  movements  (reflex  spasm).  The  child  cries  out 
at  night  as  if  in  distress,  often  without  waking.  The 
pain  varies  with  the  location  of  the  disease,  but  is  most 
commonly  abdominal;  it  may  be  entirely  absent.  When 
present,  it  is  referred  to  the  ends  of  the  pinched  spinal 
nerves.  In  the  cervical  region  the  pain  may  shoot  up 
the  back  of  the  head,  along  the  sides  of  the  neck,  or  down 
the  arms.  In  the  dorsal  region  the  pains  are  usually 
symmetrically  situated  at  the  sides  or  in  the  abdomen. 
In  the  upper  dorsal  region,  short  and  rapid  breathing 
is  common;  the  abdominal  pain  is  frequently  mistaken 
for  colic.  The  patient  walks  with  a  shuffling  gait  to  avoid 
jars,  with  shoulders  squared  and  head  thrown  back. 
Bending  forward  is  difficult.  The  child  dislikes  to  pick 
things  from  the  floor,  and  will  bend  the  knees,  holding 
the  spine  rigid  when  doing  so,  and  support  the  hands 
on  the  thighs  in  rising  (Fig.  87).  In  lumbar  disease  the 
lower  segment  of  the  spine  is  stiff  and  the  lumbar  lordo- 
sis lessened  or  effaced ;  the  pains  may  be  in  the  iliac  fossa, 
in  the  thighs,  and  even  as  low  as  the  ankle.  Local  ten- 
derness to  pressure  over  the  spine  is  an  inconstant  symp- 
tom, and  of  little  value  in  diagnosis.  Coughing,  sneez- 
ing, and  laughing  often  cause  pain,  as  do  jars  and  shocks 
from  without;  but  the  latter  should  never  be  employed 
in  examination,  as  injury  might  result.  The  fear  of  being 
handled  is  so  great,  especially  in  very  young  children, 
as  to  constitute  a  sign  of  some  importance;  all  manipu- 


DEFOKMITIES   OF    THE    SPINE 


179 


lations  in  examination  should  be  of  the  gentlest.  The 
characteristic  attitudes  and  movements  and  spinal  stiff- 
ness are  the  most  important  signs  in  beginning  cases, 
and  should  always  be  studied  after  removal  of  all  the 
clothing.  A  lead  tape  tracing  of  the  spine  with  the  child 
procumbent  should  be  taken  for  record  (Fig.  88). 


Fig.  87. — Beginning  Pott's  Disease  in  a  Boy  of  Three;  Slight 
Projection  at  First  Lumbar;  Characteristic  Posture. 

The  gibbus  appears  first  as  a  slight  but  sharp  pro- 
jection of  one  vertebra ;  unless  arrested  it  gradually  in- 
creases to  include  several  vertebrae,  finally  forming  in 
the  dorsal  region  a  large  kyphos;  so  long  as  the  projec- 
tion is  sharp,  disease  is  still  active;  the  projection  be- 


180    DEFOEMITIES    OF    NECK   AND    TEUNK 

comes  smoothly  rounded  by  the  time  the  disease  has  run 
its  course.  The  projection  is  the  center  of  the  spinal 
stiffness,  but  this  stiffness  may  extend   some  distance 


Fig.  88. — Early  Pott's  Disease  at  Ninth  Dorsal  in  Child  of  Two; 
Taking  Contour  for  Record  with  Lead  Tape. 


above  and  below;  it  is  due  to  instinctive  or  reflex  con- 
traction of  the  muscles  to  prevent  injurious  motion.  The 
spinal  stiifness  and  the  posture  characteristic  of  verte- 
bral disease  in  different  regions  should  be  carefully  stud- 
ied. Stiffness  in  the  lower  half  of  the  spine  may  be  elic- 
ited by  lifting  the  legs  during  procumbency  (Fig.  89). 
With  the  formation  of  the  kyphos  compensatory  second- 
ary changes  take  place  in  the  shape  of  the  spine  above 
and  below,  varying  with  the  location.    In  upper  dorsal 


DEFORMITIES    OF    THE    SPINE 


181 


disease  the  mid-dorsal  region  is  flattened  and  the  dorso- 
lumbar  region  has  a  rounded  kyphos,  which  is  often  mis- 
taken either  for  the  original  site  of  the  disease  or  for  a 
secondary  focus.  The  lateral  deviation  due  to  one-sided 
involvement  of  the  column  is  frequently  an  early  symp- 
tom, but  it  does  not  resemble  scoliosis,  as  the  deviation 
is  angular  and  at  the  point  of  disease,  and  is  combined 
with   stiffness    and   characteristic   postures    (Fig.    90). 


Fig.  89. — Test  for  Spinal  Stiffness;  Very  Early  Pott's  Disease. 

There  may  be  in  the  later  stages  a  true  secondary  scolio- 
sis from  mechanical  conditions. 

Complications. — An  ichor  pocket  {cold  abscess)  is 
one  of  the  most  frequent  complications,  though  many 
escape  entirely.  In  the  neck,  a  pocket  may  break  into 
the  pharynx  or  at  the  side  of  the  neck.  Upper  dorsal 
pockets  may  form  in  the  posterior  mediastinum,  and  are 


182    DEFORMITIES    OF   NECK   AND    TEUNK 


then  dangerous.    Lower  dorsal  and  lumbar  pockets  may 
appear  at  the  side  of  the  spine,  but  more  commonly  work 

along  the  psoas  muscle  or 
appear  in  the  loin.  They 
seldom  break  into  the 
abdominal  cavity,  though 
they  occasionally  pene- 
trate the  intestines.  By 
flexing  the  thigh  and  re- 
laxing the  abdominal  mus- 
cles pockets  may  often  be 
felt  in  the  iliac  fossa  be- 
fore they  reach  Poupart's 
ligament,  or  they  may 
cause  dullness  to  percus- 
sion at  the  side  of  the 
spine.  They  are  some- 
times absorbed  and  some- 
times remain  stationary 
for  an  indefinite  period. 
When  the  jDSoas  muscle 
is  irritated,  a  psoitis  is 
provoked  which  produces 
a  psoas  contraction,  with 
flexion  of  the  thigh.  Sec- 
ondary infection  of  a 
pocket  may  cause  sepsis, 
or  long-continued  suppuration  with  waxy  degeneration 
of  the  viscera,  and  death  from  kidney  complications  or 
exhaustion.  The  early  stages  of  waxy  degeneration  are 
probably  often  curable,  and  moderate  suppuration  may 


Fig.   90.  —  Lateral   Deviation   in 
Early  Pott's  Disease. 


DEFORMITIES    OF    THE    SPINE  183 

last  for  an  indefinite  period  without  serious  harm.  The 
writer  has  known  cases  where  suppuration  has  lasted 
twenty  years  or  more,  and  yet  the  patient  has  remained 
in  good  or  fair  health,  and  the  sinuses  have  finally  healed. 
Psoas  contraction  is  caused  by  the  irritation  of  fluid 
from  the  bone  focus  following  along  the  psoas  muscle. 
Psoitis  causes  flexion  of  the  thigh  and  lameness,  and  is 
not  infrequently  mistaken  for  hip  disease.  With  these 
symptoms  the  back  as  well  as  the  hip  should  be  exam- 
ined, and  it  should  be  remembered  that  both  may  be 
affected.  To  test  for  psoas  contraction  (hip  flexion), 
while  the  child  lies  prone  and  relaxed  the  ankle  is 
grasped,  the  knee  being  flexed  and  the  thigh  gently  lifted 
and  rotated.  If  hip  motion  is  free,  the  knee  can  be  read- 
ily raised  from  the  table  without  moving  the  pelvis  (hy- 
perextension  of  the  thigh)  (Figs.  144  and  145),  and  to 
an  equal  distance  on  both  sides.  If  psoas  contraction  is 
present,  the  knee  cannot  be  lifted  from  the  table  without 
lifting  the  pelvis,  or  it  cannot  be  lifted  so  far  as  on  the 
well  side.  Motion  in  psoas  contraction  is  smooth  and 
free  from  spasm,  and  extension  only  is  limited;  in  hip 
infections  there  is  muscular  spasm,  and  rotation,  as  well 
as  extension,  is  limited.  Psoas  contraction  may  be  slight 
and  may  pass  away  without  the  appearance  of  an  ab- 
scess, or  it  may  be  severe  and,  in  a  few  cases,  persist 
as  a  permanent  flexion  from  fibrous  shortening.  In 
psoas  contraction  a  fluctuating  mass  should  always  be 
looked  for  in  the  groin,  iliac  fossa,  or  loin.  The  treat- 
ment is  the  treatment  of  the  vertebral  disease,  and  so 
long  as  psoas  contraction  is  present  recumbency  should 
be  emphasized  in  addition  to  spinal  support. 


184    DEFORMITIES    OF    NECK   AND    TRUNK 


Another  alarming  complication  is  paraplegia,  due  to 
pachymeningitis  or  the  jDressure  of  inflammatory  prod- 
ucts, which  occurs  in  perhaps 
ten  per  cent  of  the  cases. 
Weakness  often  appears  first 
in  one  leg,  but  soon  involves 
both,  and  may  progress  to 
total  motor  paralysis.  If 
sensory  paralysis  is  added 
the  lesion  is  more  severe  and 
the  prognosis  graver.  The 
reflexes  are  usually  in- 
creased, though  in  the  later 
stages  of  some  cases  they 
may  be  abolished.  In  the 
severe  dorso-lumbar  cases 
the  control  of  bladder  and 
rectum  may  be  impaired  or 
lost.  One  should  distinguish 
between  automatic  micturi- 
tion and  defecation,  reflex 
phenomena,  and  retention 
with  dribbling  due  to  palsy 
of  the  centers;  the  latter  is 
the  graver.  Both  ichor  pock- 
ets and  paralysis  are  rarer 
under  mechanical  support. 
There  is  a  strong  tendency 
of  the  inflammatory  products 
and  thickened  tissues,  which  press  on  the  cord,  to  be 
absorbed  or  reduced  by  rest  and  splinting. 


Fig.  91. —  Pott's  Disease  at 
THE  Second  Cervical  in  a 
Child  Two  Years  Old.  The 
head  drops  forward  and  is 
often  supported  by  the  hands. 


DEFORMITIES    OF    THE    SPINE 


185 


Under  protective  treatment  the  prognosis  is  decidedly 
good,  even  in  long-standing  cases,  and  laminectomy  is 
very  rarely  indicated. 

Differential  Diagnosis. — The  range  of  diseases  for 
which  Pott's  disease  may  be  and  has  been  mistaken  is 
very  wide.  In  the 
neck  it  may  be  taken 
for  torticollis,  in  the 
thoracic  region  for 
disease  of  the  lungs 
or  abdomen,  and  in 
the  loins  for  kidney, 
appendical,  or  blad- 
der disease.  The  af- 
fections from  which 
it  most  needs  to  be 
distinguished  are  ra- 
chitic spine,  "  rheu- 
matoid"  spine, 
round  back,  lateral 
curvature,  and  neu- 
rotic spine;  it  must 
also  be  differenti- 
ated from  hip  dis- 
ease, sacro-iliac  dis- 
ease, perinephritic 
abscess,  and  abdom- 
inal adenitis. 

The  diagnosis  of 
cervical  spondylitis 
from    acute    or    in- 

14 


Fig.  92. — Upper  Dorsal  Pott's  Disease  in 
A  Girl  of  Five,  who  has  Worn  a  Jacket 
WITH  Jury  Mast  Two  Years.  The  dis- 
ease is  quiescent  but  not  cured. 


186    DEFORMITIES    OF    NECK    AND    TRUNK 


fectious  torticollis  is  not  always  easy.  The  invasion  of 
spondylitis  is  usually  slower  and  more  insidious ;  a  pro- 
jection is  often  felt 
in  the  neck,  and  the 
posture  and  care  in 
supporting  the  head 
are  often  character- 
istic. 

In  rachitic  spine,  a 
rounded  back  from  re- 
laxation, the  child  has 
the  symptoms  of  rick- 
ets, which  are  usually 
absent  in  Pott's  dis- 
ease; the  curve  is 
rounded,  mainly  be- 
low the  shoulder- 
blades,  and  partly  or 
wholly  disappears  in 
the  prone  posture 
(Figs.  105  and  106). 
There  is  no  charac- 
teristic pain  and  no 
reflex  spasm.  In  Pott's 
disease  the  projection 
is  in  the  active  stage 
nearly  always  sharp, 
and  confined  to  one  or 
two  vertebrae.  There  is  local  stiffness,  and  the  deform- 
ity does  not  disappear  when  the  patient  is  prone. 

In  ankylosing  arthritis  there  is  stiffness,  which  may 


Fig.  93. — Lumbar  Pott's  Disease;  the 
Posture  Indicates  that  Disease  is 
Still  Active. 


DEFOEMITIES    OF    THE    SPINE  187 

be  local  or  general,  with  or  without  a  round  back  or  sco- 
liosis; other  joints  may  be  involved.  There  is  no  sup- 
puration, and  no  localized  or  sharp  projection  (Fig.  108). 

Scoliosis  and  round  back  should  be  easily  excluded, 
as  there  is  no  characteristic  pain  or  muscular  spasm, 
and  the  posture  is  different ;  in  the  severe  cases  the  spine 
may  be  more  or  less  stiff. 

In  neurotic  spine,  backache  and  spinal  tenderness  are 
present,  but  there  is  no  characteristic  pain  or  deformity. 
There  is  tenderness  to  light  pressure  over  the  spinous 
processes  or  the  vertebral  arches,  which  may  be  extreme. 
It  may  be  in  any  region  or  affect  the  whole  spine;  the 
upper  cervical,  interscapular,  lumbar,  and  coccygeal  re- 
gions are  favorite  sites.  Similar  tenderness  often  exists 
over  the  bony  prominences  of  the  pelvis  or  in  the  iliac 
fossa,  and  elsewhere,  and  symptoms  of  hysteria  or  neu- 
rasthenia are  usually  present.  Spinal  hyperesthesia  is 
not  characteristic  of  spondylitis,  and  pains  induced  by 
moderate  pressure  along  the  spine  are  indicative  of  a 
neurotic  spine  rather  than  of  Pott's  disease. 

A  psoas  contraction  may  be  mistaken  for  hip  disease, 
but  there  is  limitation  to  extension  only,  and  no  spasm; 
in  hip  disease  there  is  usually  some  limitation  in  all  di- 
rections, or  at  least  to  rotation,  even  in  the  early  stages. 
One  should,  however,  remember  that  tuberculosis  of  the 
hip  and  spine  may  coexist.  Pain  across  the  back  of  the 
pelvis,  with  tenderness  over  the  sacro-iliac  joint,  and 
disability  and  pain  in  standing,  sitting,  and  lying,  are 
indicative  of  sacro-iliac  disease. 

Carcinoma  of  the  spine  is  rare,  and  usually  secondary ; 
in  it  the  pain  is  agonizing,  and  unrelieved  by  support. 


188    DEFORMITIES    OF   NECK   AND    TRUNK 

In  perinephritic  abscess  (Fig.  94),  appendicitis,  tn- 
bercnlosis  of  the  abdominal  glands,  and  other  inflamma- 
tory abdominal  affections  there  may  be  thigh  flexion  and 
spinal  stiffness,  and  the  postures  may  suggest  spinal  in- 


FiG.  94. — Perinephritic  Abscess  op  Left  Loin,  Simulating  Spinal  Ab- 
scess. Symptoms  one  week,  abdominal  rigidity.  Abscess  showed 
staphylococci. 

volvement.  In  these  affections,  however,  there  is  nearly 
always  more  or  less  involuntary  abdominal  rigidity  over 
the  affected  area,  which  in  the  case  of  diseased  glands 
may  be  below  the  sternum. 

Treatment. — The  objects  of  treatment  are  to  im- 
prove nutrition,  to  enforce  spinal  rest  in  order  to  favor 
healing,  and  to  prevent  deformity. 

The  nutritional  indication  is  common  to  all  chronic 
tuberculous  lesions,  and  is  met  by  fresh  air,  sunlight,  and 
generous  feeding,  including  fats.  The  second  and  third 
indications  are  met  by  periods  of  recumbency,  by  splints, 
jackets,  and  frames,  and  by  the  strict  avoidance  of  stren- 
uous activity  and  of  movements  and  jars  affecting  the 
spine.     The  patient  should  never  sit  up  without  spinal 


DEFORMITIES    OF    THE    SPINE  189 

support,  which  should  be  worn  day  and  night;  when  the 
support  is  removed  the  patient  should  be  rolled  over, 
not  lifted. 

In  children  of  two  years  or  under  the  gas-pipe  or 
wire  frame,  as  modified  by  Whitman,  is  the  best  sup- 
port (Fig.  95).  It  is  made  of  quarter-inch  (caliber)  gas 
pipe,  and  is  five  or  six  inches  wide  and  a  foot  longer 
than  the  child.  It  is  covered  by  a  canvas  lacing,  and 
should  be  bent  up  in  the  region  of  the  kyphos,  where 
felt  pads  are  added  to  exert  greater  leverage.  The  can- 
vas is  protected  in  its  middle  half  by  a  rubber  cloth,  and 
the  child  is  strapped  to  the  frame  by  a  broad  apron  with 
webbing  straps  at  the  sides  fastening  into  buckles  on  the 
back  of  the  canvas.     The  skin  of  the  back  should  be  in- 


FiG.  95. — Whitman's  Gas-pipe  Frame. 

spected  daily  and  kept  powdered  and  dry.  The  clothing 
should  be  adjusted  over  the  frame,  and  the  child  may 
be  carried  about  on  it,  as  on  a  pillow.  A  small  child 
may  be  kept  on  such  a  frame  for  a  year  or  two,  if  nec- 
essary. When  desirable,  T-shaped  attachments  may  be 
added  for  extension  at  the  feet  and  head,  in  which  case 
the  frame  should  be  six  inches  longer. 

After  the  age  of  two  and  a  half  or  three,  antero- 


190    DEFORMITIES    OF    NECK    AND    TRUNK 


posterior  support  may  be  furnished  by  a  steel  brace  or 
by  a  jacket.  The  advantages  of  a  fixed  plaster-of -Paris 
jacket  are  that  it  is  applied  by  the  physician  hinrself, 
and  that  it  must  remain  in  place  until  removed   (Fig. 

96).  Its  disadvantages 
are  that  it  is  uncleanly, 
and  does  not  permit  in- 
spection of  the  spine  or 
ready  readjustment.  The 
points  in  its  favor,  how- 
ever, are  so  important  as 
to  make  it  the  favorite 
method  in  dispensary 
practice,  and  with  those 
who  are  unfamiliar  with 
the  management  of  ap- 
paratus. If  the  disease 
is  above  the  tenth  dorsal 
the  leverage  should  be 
increased  by  a  head  or 
chin  support,  whether  a 
jacket  or  brace  is  em- 
ployed. Removable  jack- 
ets or  corsets  are  not  so 
efficient  or  useful  as  fixed 
jackets,  except  in  select- 
ed cases  under  strict  con- 
trol and  in  convalescents. 
The  best  material  for  a 
jacket  is  plaster-of -Paris, 
and  it  is  usually  applied 


Fig.  96. — Plaster  Jacket  with  Jury 
Mast,  Just  Applied.  Note  tilting 
back  of  head.  The  stockinette 
hanging  down  will  be  turned  up 
over  the  jacket  and  sewed  to  itself 
at  the  top. 


DEFORMITIES    OF    THE    SPINE 


191 


with  the  patient  vertically  suspended  or  partly  suspend- 
ed from  the  chin  and  occiput.  It  may  be  applied  with 
the  patient  horizon- 
tally suspended  on  a 
frame  or  hammock. 
The  jacket  should 
be  applied  with  the 
spine  in  hyjjerexten- 
sion,  and  should  be 
changed  every  two  or 
three  months;  thick 
felt  pads  should  be 
used  either  side  of 
the  kyphos  for 
stronger  leverage. 
Many  jackets  are  in- 
efficient because  they 
are  not  made  long- 
enough  or  are  not 
molded  to  properly 
distribute  the  pres- 
sure. The  front  and 
back  of  the  jacket, 
according  to  Calot, 
are  united  over  the 
shoulders  (Fig.  97), 
and  if  the  disease  is 
above  the  ninth  dor- 
sal, the  neck,  chin,  and  occiput  are  included  (Figs.  98 
and  99).  A  large  fenestra  is  cut  out  in  front,  to  in- 
crease comfort,  and  a  smaller  one  behind,  over  the  ky- 


]      *- 

^^fe^^^^^^^^^H^^ 

1 

i 

1 

Fig.  97. — Calot  Jacket  Reaching  over 
THE  Shoulders,  and  with  Fenestra  in 
Front  and  Behind. 


192    DEFORMITIES    OF    NECK    AND    TRUNK 

phos,  through  which  cotton  is  stuffed  either  side  of  the 
spine  to  increase  the  pressure ;  the  fenestra  is  then  filled 


Fig.  98.  Fig.  99. 

Figs.  98  and  99. — Upper  Dorsal  Pott's  Disease  ;  Recovery  from  Press- 
ure Paraplegia  Under  the  Calot  Jacket,  with  Recumbency.  Pa- 
tient at  Hospital  for  Ruptured  and  Crippled.  Front  and  back  view  of 
the  same  patient. 

up  with  tightly  packed  cotton,  which  is  kept  in  place  by 
a  bandage.    By  inserting  fresh  cotton  as  the  old  becomes 


DEFORMITIES    OF    THE    SPINE 


193 


packed  down,  the  leverage  is  kept  at  its  maximum.  It 
should  be  stated  that  Calot  keeps  most  of  his  cases 
recumbent.  Forcible  cor- 
rection of  the  kyphos  can- 
not be  commended.  When 
good  cooperation  and  regu- 
lar attendance  can  be  se- 
cured, especially  in  private 
practice,  a  steel  and  leath- 
er leverage  splint  with  an 
apron,  permitting  frequent 
bathing,  and  inspection  and 
readjustment  when  neces- 
sary, is  preferable  in  the 
hands  of  an  expert  (Fig. 
100).  The  chin  rest  is  to 
be  added  for  disease  above 
the  tenth  dorsal.  When 
the  posture  is  bad  or 
pains  persist,  the  patient 
should  be  put  to  bed  in  ad- 
dition, for  several  weeks 
or  months ;  it  is  well  to  pre- 
scribe several  hours  of  re- 
cumbency daily,  as  well  as 
long  night  rests.  Indeed, 
during  the  active  stage  it 
is  best  to  keep  the  child  from  school,  and  to  allow  only 
so  many  hours  out  of  bed  morning  and  afternoon,  as 
his  condition  may  warrant. 

The  immediate  effects  of  efficient  spinal  support  are 


Fig.    100.— C.    F.   Taylor's  Spinal, 
Splint  with  Head  Support. 


194    DEFOEMITIES    OF    NECK    AND    TRUNK 


very  striking.  Most  patients  are  relieved  of  their  pain  at 
once  or  in  a  few  days,  their  appetite  and  general  condition 
improve,  and  they  become  more  active.  Many  cases  be- 
come so  free  from  symptoms  that  the  physician  is  tempt- 
ed to  intermit  or  discon- 
tinue the  spinal  support 
and  the  periods  of  recum- 
bency. This  temptation 
should  be  steadfastly  re- 
sisted, as  the  disease  is 
rarely  cured  in  two  years, 
and  then  only  in  the  cer- 
vical region.  In  other  re- 
gions spinal  support  for 
four  to  five  years  or  more 
is  necessary.  If  abdomin- 
al or  other  characteristic 
pain  recurs,  if  the  pa- 
tient's general  condition 
is  unsatisfactory,  or  if  he 
leans  to  one  side  or  does 
not  hold  himself  well, 
spinal  support  should  be 
improved  and  the  patient 
put  to  bed  for  a  time. 

When  to  Leave  Of  Spi- 
nal Support. — The  spine 
should  be  splinted  for  a 
year  or  more  after  all 
active  symptoms,  includ- 
ing reflex  spasm  of  the 


Fig.  101. — Lower  Lumbar  Pott's  Dis- 
ease, Cured  after  Six  Years' 
Support  with  Plaster  Jackets, 
AND  One  with  Plaster  Corset. 
Boy  op  Ten.  Has  been  one  year 
without  support. 


DEFORMITIES    OF    THE    SPINE 


195 


spinal  muscles,  are  i"»ast.  The  spinal  deformity  must  be 
rounded  and  the  patient  must  be  able  to  hold  himself 
well  without  support. 
Growth  in  children 
should  be  increased  to 
one  and  a  half  or  two 
inches  a  year.  It  is 
usually  necessary  to 
prolong  the  support, 
except  at  night,  for  a 
considerable  time  af- 
ter an  anatomical  cure, 
in  order  to  prevent  the 
gradual    increase    of 


the  kyphos  from  static 
conditions.  This  often 
takes  place  without 
recurrence  of  disease. 
Support  should  be  dis- 
continued by  degrees ; 
at  first  at  night,  later 
a  few  hours  at  a  time 
in  the  daytime.  It  is 
best  to  continue  to  ab- 
stain from  active  ex- 
ercise, and  to  prolong 
the  hours  of  recum- 
bency for  a  consider- 
able time. 

Prognosis. — There  is  a  strong  tendency  to  self -limi- 
tation and  a  natural  cure,  but  the  course  in  untreated 


Fig.  102. — Untreated  Pott's  Disease;  it 
Began  at  Five  Years  of  Age,  and  at 
THE  Ninth  Dorsal  Vertebra  ;  No  Ab- 
scess OR  Paralysis  ;  Girl  of  Eighteen. 


196    DEFORMITIES    OF    NECK    AND    TEUNK 


cases  is  very  long  (five  to  twenty  years),  and  many  die 
of  tuberculous   meningitis,   general   tuberculosis,    waxy 

viscera,  exbauscion, 
or  intercurrent  af- 
fections. The  result- 
ing deformity  is  se- 
vere and  the  effect 
on  the  constitution  is 
profound  (Figs.  102 
and  103). 

Under  efficient  hy- 
gienic and  protective 
treatment  the  mor- 
tality is  smaller,  the 
complications  are 
rarer  and  less  seri- 
ous, and  the  final  de- 
formity is  less  (Fig. 
104).  The  results 
are  better  in  private 
than  in  hospital  and 
dispensary  practice. 
Occasionally  cures 
are  obtained  with 
little  or  no  deform- 
ity, and  in  exception- 
al cases  marked  de- 
formity may  recede 
under  treatment;  but  as  a  rule  deformity  progresses 
slowly  for  a  number  of  years,  though  pain  and  acute 
symptoms  are  quickly  relieved,  and  the  final  result  is 


Fig.  103. — Dorsal  Pott's  Disease  in  Girl 
OF  Seven;  Three  Years  Duration;  No 
Spinal  Support;  Disease  Still  Active. 
Compare  Fig.  104. 


DEFORMITIES    OF    THE    SPINE 


197 


recovery  with  more  or  less, 
often  considerable,  defor- 
mation. 

Tuberculous  disease  of 
the  atloido-oxoid  and  occip- 
ito-atloidean  articulations 
has  been  called  spondylar- 
thritis tuberculosa. 

On  account  of  the  close 
proximity  of  the  affected 
structures  to  the  spinal 
cord,  the  latter  is  often 
compressed  with  resulting 
paralysis,  at  first  of  the 
arms ;  pharyngeal  abscess 
may  occur,  and  brawny  in- 
duration of  the  upper  neck 
is  often  noticed.  When  one 
side  is  more  affected  the 
head  is  turned  to  one  side; 
the  neck  is  held  stiif  and 
pressure  is  very  painful; 
the  pain  is  referred  to  the 
back  of  head  and  ear ;  there 
may  be  tongue  and  eye 
symptoms. 

The  treatment  is  the  same  as  for  cervical  Pott's 
disease. 

Tuberculosis  of  the  abdominal  glands,  particularly  of  the 
mesenteric  glands,  may  cause  spinal  stiifness  and  disa- 
bility, and  may  end  in  abscesses  and  sinuses.     There  is 


Fig.  104. — Pott's  Disease  at  Elev- 
enth Dorsal,  Convalescent 
WITH  Slight  Deformity  After 
Five  Years  op  Spinal  Support; 
Girl  of  Nine. 


198    DEFORMITIES    OF    NECK   AND    TRUNK 

more  or  less  abdominal  rigidity,  sometimes  enlargement, 
particularly  at  the  npper  part,  and  with  sjnuptoms  of 
toxemia.  The  spine  may  or  may  not  be  secondarily  dis- 
eased, but  is  usually  stiffened.  There  is  no  sharp 
kyphos,  but  there  may  be  a  rounded  curve. 

The  rachitic  spine,  considered  here  for  convenience,  is 
the  postural  backward  curve  of  the  spine  often  seen  in 


Fig.  105. — Rachitic  Spine  in  a  Child  One  Yeae  Old. 


rachitic  infants,  particularly  when  sitting.  The  curve 
may  involve  the  dorsal  and  lumbar  regions,  or  only  the 
lower  part  of  the  spine,  is  never  sharp,  and  disappears 


DEFORMITIES    OF    THE    SPINE  199 

or  is  diminished  in  the  prone  posture;  reflex  spasm  is 
absent  (Figs.  105  and  106).  The  treatment  is  that  of 
rickets,  with  recumbency  added.  A  frame  may  be  used 
to  prevent  sitting  in  the  bad  cases,  if  desired;  jackets 


Fig.  106. — Same  as  Fig.  105;  Showing  Disappearance  op  Kyphos  in 
Prone  Posture. 

and  braces  are  unnecessary.  A  similar  condition  may 
exist  iQ  other  forms  of  infantile  malnutrition,  as  in 
myxedema,  scurvy,  chondrodystrophia,  and  marasmus, 
in  each  of  which  the  primary  condition  will  require 
appropriate  management. 

Spondylitis  Traumatica  {KummeVs  Disease). — A  severe 
injury  of  the  spiae,  from  a  fall  or  blow,  may  produce 
immediate  and  obvious  symptoms  of  fracture  or  other 
gross  injury  of  the  siDinal  column,  including  spinal  de- 
formity and  paraplegia.  In  less  severe  injuries  the 
spinal  symptoms  may  at  first  be  mild  or  absent;  there 
may  or  may  not  be  a  slight  projection  at  the  point  of 


200    DEFOEMITIES    OF    NECK    AND    TRUNK 

injury,  but  if  absent  a  prominence  is  noticed  a  month 
or  two  later,  which  slowly  increases.  There  are  spinal 
stiffness,  pain  in  the  back,  side,  or  abdomen,  and  inability 
to  stoop.  The  original  injury  was  probably  a  crush, 
crack,  or  bruise  of  one  or  more  vertebral  bodies  without 
much  displacement;  this  was  followed  by  a  traumatic 
rarefying  ostitis  of  the  implicated  vertebral  bodies. 
The  symptoms  are  milder  than  in  spinal  tuberculosis; 
the  projection,  which  is  usually  in  the  middle  of  the  back, 
is  more  rounded.  The  course  of  the  disease  is  shorter, 
and  the  ultimate  deformity  less.  There  is  little  or  no 
tendency  to  suppuration. 

The  TREATMENT  is  spiual  support  and  fixation  by 
braces  or  jackets ;  the  relief  is  usually  prompt,  and  most 
cases  terminate  in  cure  in  a  year  or  two,  with  some  stiff- 
ness and  slight  deformity  at  the  point  of  injury. 

Spinal  support  may  also  be  indicated  in  sprains  of 
the  spinal  ligaments,  if  the  soreness,  stiffness,  and  dis- 
ability do  not  pass  off  in  a  few  days  or  weeks. 

Typhoid,  syphilitic,  actinomycotic,  and  pus  infections  of 
the  spinal  column  are  rare,  but  the  possibility  of  their 
occurrence  is  to  be  borne  in  mind. 

Progressive  Ankylosis  of  the  Spine. — Under  this  title  may 
be  grouped  a  number  of  chronic  pathological  processes 
affecting  the  spine  or  its  ligaments  which  result  in  spinal 
stiffness,  often  with  pain  and  deformity,  but  with  no 
tendency  to  suppuration.  The  process  may  affect  the 
greater  part  or  whole  of  the  spine,  or  may  be  confined  to 
a  few  vertebrae  only.  In  osteoarthritis  of  the  spine  the 
lateral  bands  of  the  anterior  spinal  ligaments  become 
ossified,  the  rims  of  the  vertebrae  may  become  lipped, 


DEFORMITIES    OF    THE    SPINE 


201 


and  may  fuse  with  growths  from  neighboring  vertebrae 
(Fig.  107).  If  ankylosis  takes  place  quickly  there  is 
little  or  no  deformity;  if  slowly,  extreme  round  back  or 
scoliosis  may  result.  The  larger  joints,  particularly  the 
hips  and  shoulders,  may  be  similarly  affected  (Fig.  108). 


Fig.   107. — Osteoarthritis  of  the  Spine. 
(Specimens  from  Cornell  Medical  College.) 


In  the  atrophic  type  without  osteophytes  the  small  spinal 
articulations  and  the  joints  of  the  hand  and  feet  are 
often  affected.  In  still  another  form  the  supraspinous 
ligaments  may  become  ossified  (Elliott). 

Many  cases  are  due  to  infection,  particularly  to  gon- 

15 


202    DEFORMITIES    OF    NECK   AND    TRUNK 

orrhea,  and  occur  most  frequently  in  young  adults;  in 
others,  exposure  to  cold  and  wet  seems  to  be  the  exciting 
cause.  Some  cases  seem  to  be  due  to  intestinal  auto- 
intoxication or  nutritional  disturbances.    There  may  be 


Fig.  108. — Ankylosing  Arthritis  of  the  Spine,  Hips  and  One  Shoul- 
der.    The  Disease  Began  at  Eight  Years  of  Age.     (Hospital  for 
the  Ruptured  and  Crippled.) 

referred    pains    from    nerve    pressure,    and    abdominal 
breathing  from  ankylosis  of  the  ribs. 


DEFORMITIES    OF    THE    SPINE  203 

In  many  of  the  early  cases  spinal  support  by  jackets 
or  braces,  by  allaying  irritating  pressure  and  friction, 
relieves  the  pain,  and  not  infrequently,  especially  when 
combined  with  nutritious  diet  and  tonic  treatment,  or 
the  treatment  of  intestinal  putrefaction  (mineral  acids 
and  soured  milk),  shortens  the  morbid  process  and  leads 
to  a  complete  cure,  so  that  all  symptoms  except  local 
stiffness  disappear,  and  the  patient  is  able  to  go  back 
to  work.  Antirheumatic  treatment  and  a  low  diet  are 
often  harmful.  When  the  process  has  run  its  course, 
and  extensive  ankylosis  has  taken  place,  there  is  little 
to  be  done  so  far  as  the  spine  is  concerned. 

Neurotic  spine,  while  not  pathological,  is  considered 
here  for  convenience.  There  is  a  large  class  of  neu- 
rotics, many  of  them  bed-ridden,  and  suffering  from  hys- 
terical or  neurasthenic  symptoms,  who  attribute  great 
importance  to  spinal  pain,  tenderness,  and  weakness. 
These  patients  in  not  a  few  instances  have  been  sent  to 
bed  by  their  physicians,  sometimes  under  a  mistaken 
diagnosis  of  spinal,  pelvic,  or  other  organic  disease,  and 
they  often  remain  in  bed  for  years,  in  helpless  invalidism, 
until,  under  the  stimulus  of  some  strong  personality, 
medical  or  lay,  their  apprehension  of  imminent  disaster 
is  removed,  and  they  will  to  make  the  exertion  to  get  up. 
Lesser  degrees  of  invalidism,  combined  with  spinal  weak- 
ness and  backache,  are  very  common;  if  an  old  lateral 
curvature  is  present,  however  slight,  it  is  claimed  to  be 
proof  positive  of  the  spinal  origin  of  the  mischief.  The 
pain  in  these  cases  is  often  severe  and  increased  on  ex- 
ertion, and  there  may  be  spots  of  exquisite  tenderness 
to  slight  pressure  up  and  down  the  spine,  over  the  pelvic 


204    DEFOEMITIES    OF    NECK    AND    TRUNK 

and  other  bony  prominences,  and  in  tlie  iliac  fossse.  Neu- 
rasthenic or  hypochondriac  symptoms,  with  or  without 
intestinal  indigestion,  are  usually  present,  while  those 
of  organic  disease  are  lacking.  These  cases  are  in  a 
pitiable  condition  and  merit  serious  treatment,  especially 
as  the  prognosis  under  rational  management  is  very 
good. 

Local  treatment,  including  spinal  support,  is,  as  a 
rule,  to  be  avoided.  The  patient  should  be  assured  of 
the  curability  of  the  condition,  and  trained  in  moderate 
and  regular  exertion.  Mild  tonics,  massage,  active  and 
passive  movements,  nutritious  diet,  and  other  measures 
to  improve  digestion,  nutrition,  and  elimination,  should 
be  prescribed.  Of  more  service  than  any  other  one  thing, 
except  inspiring  the  patient  with  confidence  and  hope, 
and  often  giving  brilliant  results,  is  the  use  of  a  power- 
ful vibrator,  applied  with  moderate  pressure  the  length 
of  the  spine  on  either  side  of  the  spinous  processes  in 
the  interval  between  the  arches,  a  few  seconds  at  each 
spot.  The  tonic  effect  of  this  measure,  when  properly 
carried  out,  is  usually  prompt  and  surprisingly  good. 
The  symptoms  complained  of  often  disappear  in  a  few 
weeks  under  moral  support  and  proper  training,  and 
patients  who  have  been  utterly  helpless,  and  even  con- 
fined to  the  bed  for  years,  have  in  numerous  instances 
been  restored  to  health  and  usefulness. 


DEFOBMITIES    OF    THE    SHOULDER-GIRDLE 
AND    UPPER    EXTREMITY 

GENERAL 

The  upper  extremity  is  characterized  by  its  penden- 
cy, and  by  the  variety  and  range  of  its  movements;  in 
a  reasonably  snpple  person  there  is  no  part  of  the  sur- 
face of  the  body  that  is  beyond  the  reach  of  the  fingers. 
Many  employments  require  free  use  of  the  hand  and 
arm.  It  is  particularly  important  in  daily  life  that  the 
head  and  face  should  be  within  reach  of  the  hands ;  this 
can  be  done  with  the  elbow  flexed  beyond  a  right  angle, 
even  if  it  is  stiff.  Many  arm  movements  are  made  from 
the  sterno-clavicular  joint  as  a  center,  and  the  sliding 
of  the  scapula  over  the  posterior  thorax  may  compen- 
sate to  a  considerable  extent  for  stiffness  at  the  shoulder- 
joint.  The  absence  of  weight-bearing  accounts  for  the 
less  frequent  occurrence  of  rachitic  curvatures  of  the 
arm  bones  and  of  tuberculous  affections  of  the  joints 
of  the  upper  extremity. 

SHOULDER-GIRDLE 

Clavicle 

The  clavicles  may  be  partly  or  entirely  absent  on  one 
or  both  sides.  This  deformity,  however,  is  very  rare. 
The  shoulders  drop  forward  and  inward,  but  the  dis- 
ability is  slight. 

205 


206     DEFORMITIES    OF    SHOULDER-GIEDLE 

Fracture  of  the  clavicle  may  occur  from  injury  at  birth. 
The  clavicle  may  be  chronically  subluxated  at  its  sternal 
or  acromial  end.  In  all  these  conditions,  and  in  recent 
fracture  in  children  and  adults,  C.  F.  Taylor's  clavicle 
splint  gives  excellent  results  (Figs.  109  and  110).  It 
consists  of  an  adjustable  curved  steel  band  carrying  a 
long  23ear-shaped  pad  at  each  end,  to  which  the  straps 
from  a  large  stiff  scapular  pad  are  attached.  It  acts 
as  a  double  clavicle,  opposing  the  forward  droop  of  the 
shoulders  and  the  tilting  of  the  scapulae,  and  at  the  same 


Figs.  109  and  110. — -C.  F.  Taylor's  Splint  for  Fractured  Clavicle. 


time  permits  the  free  use  of  the  injured  arm.     It  has 
proved  very  satisfactory  in  practice. 

Many  fractures  of  the  clavicle  in  young  children  show 
little  or  no  tendency  to  displacement,  and  such  cases 
require  no  treatment  beyond  the  suspension  of  the  arm 
in  a  sling,  or,  better,  by  a  neck  halter,  or  by  pinning 
the  end  of  the  sleeve  high  up  to  the  neck  of  the  coat 


SCAPULA 


207 


or  dress  (Fig.  111).  This  management  has  been  prac- 
ticed by  the  writer  in  the  majority  of  fresh  fractures 
of  the  clavicle  in  young  children  seen  by  him,  and  gives 
as  good  results  as 
any  form  of  splint- 
ing with  a  minimum 
of  confinement  and 
discomfort. 

Scapula 

The  scapulae  vary 
greatly  in  size  and 
shape  in  different  in- 
dividuals ;  many  of 
these  variations  are 
unimportant,  while 
others  must  be  taken 
into  account.  Such 
are  the  length  and 
position  of  the  cora- 
coid  process,  which 
sometimes  impinges 
upon  the  tuberosity 
of  the  humerus,  caus- 
ing pain  and  irrita- 
tion when  the  shoul- 
der droops  forward 
(Goldthwait). 

Bowed  Scapula. — In  certain  persons  the  scapulse  are 
bowed  by  the  bending  forward  of  the  upper  angle  or 
margin,  usually  in  adaptation  to  the  droop-shoulder  pos- 


FiG.  111. — Safety-pin  Dressing  for  Frac- 
ture OF  the  Clavicle  in  Children. 


208     DEFOEMITIES    OF    SHOULDER-GIRDLE 

ture;  the  projecting  part  may  cause  pain  by  rubbing 
against  the  ribs,  and  may  form  an  obstruction  to  correc- 
tion of  posture.  The  rubbing,  which  may  be  felt  v^hen 
the  scapula  is  moved,  was  formerly  thought  to  be  due 
to  a  bursitis,  but  its  true  nature  was  pointed  out  by 
Goldthwait,  who  has  obtained  excellent  results  by  excis- 
ing the  projecting  part. 

Goldthwait's  operation  for  correction  of  bowed  scap- 
ula is  by  removal  of  its  upper  portion.  An  incision 
three  inches  long  is  made  just  above  and  parallel  to  the 
spine  of  the  scapula.  In  order  to  leave  a  less  conspicu- 
ous scar,  the  incision  in  women  may  curve  from  the 
lower  part  of  the  scapula  to  near  the  acromion.  The 
skin  and  fascia  are  dissected  back  to  the  attachment  of 
the  trapezius  to  the  spine  of  the  scapula;  this  attach- 
ment is  divided  for  two  inches  from  the  inner  edge.  The 
supraspinatus  muscle  is  exposed  and  scraped  back  from 
the  part  to  be  removed,  and  the  tendon  of  the  levator 
anguli  scapuli  is  separated  by  the  periosteal  elevator, 
but  not  divided.  Enough  of  the  upper  part  of  the  scapula 
is  then  removed  with  the  bone  forceps  to  permit  the 
scapula  to  lie  flat  in  its  normal  position  without  rub- 
bing against  the  ribs.  The  trapezius  is  sutured  and  the 
wound  closed  without  drainage,  and  dressed  with  gauze 
and  a  bandage.  The  patient  is  usually  up  in  a  week, 
and  using  the  arms  in  two  weeks.  Developing  exercises 
and  posture  training  should  follow. 

Congenital  Elevation  of  the  Scapula. — In  this  deformity 
(Sprengel's)  the  scapula  and  shoulder  of  the  affected 
side  are  higher  than  normal;  they  have  not  fully  de- 
scended from  the  higher  position  normal  to  the  early 


SCAPULA  209 

stages  of  development.  The  scapula  may  be  small,  and 
is  so  rotated  that  the  inferior  angle  approximates  the 
spinal  column.  The  affection  is  occasionally  bilateral, 
and  may  be  associated  with  other  congenital  malforma- 
tions. When  unilateral  there  is  often  a  cervico-dorsal 
lateral  curvature  of  the  spine  convex  to  the  affected 
side;  there  is  no  paralysis,  and  the  movements  of  the 
shoulder- joint  are  free.  In  a  few  cases  the  upper  part 
of  the  scapula  is  joined  to  the  spine  by  a  bony  process, 
which  may  require  excision.  The  disability  for  ordinary 
movements  is  usually  slight,  though  the  deformity  may 
be  considerable.  Eemedial  gymnastics  will  sometimes 
effect  improvement. 

Forward  shoulders  is  a  better  term  than  round  or  droop 
shoulders  for  the  persistent  forward  posture  of  the 
shoulders  determined  by  the  position  of  the  scapulae; 
it  is  the  characteristic  posture  of  weakness  and  relaxa- 
tion of  the  shoulders,  and  usually  accompanies  or  is 
secondary  to  a  weak  and  round  back  and  general  faulty 
development.  It  should  be  remembered  that  the  center 
of  motion  of  the  shoulder,  as  a  whole — not  the  shoul- 
der-joint— is  the  sterno-clavicular  joint,  since  this  is  its 
only  articulation  with  the  thorax.  In  forward  shoul- 
ders, the  muscles  which  bind  the  scapula  to  the  spine 
and  give  it  its  only  posterior  support  are  relaxed  and 
lengthened,  and  the  scapulae  slide  forward  and  outward. 
When  this  has  persisted  as  the  habitual  posture  for  a 
long  time,  the  serrati  magni  become  contracted ;  the  pec- 
torals, contrary  to  received  opinion,  do  not  (Fitz).  In 
extreme  cases  the  coraco-clavicular  and  the  acromio- 
clavicular ligaments  may  be  shortened,  and  the  scapulae 


210     DEFOEMITIES    OF    SHOULDER-GIEDLE 

may  be  bowed.  The  treatment  includes  proper  hygiene, 
and  the  toning  np  and  development  of  the  muscular 
system  in  proper  postures.  Some  inveterate  cases  may 
require  forcible  correction  and  retention,  with  straight- 
ening of  the  dorsal  spine  and  approximation  of  the 
scapulae.  The  treatment  of  the  concomitant  round  back 
is  often  more  important  than  the  treatment  of  the  shoul- 
ders. Posture  must  be  corrected  from  feet  to  chin,  not 
trunk  or  back  alone,  still  less  shoulders  alone.  This 
includes  straight  foot  standing,  and  straight  back  stand- 
ing and  sitting,  with  stretching  of  the  serrati  and 
strengthening  of  the  trapezii  and  rhomboidei.  The  am- 
biguity of  the  phrase  "  put  your  shoulders  back  "  should 
be  recognized  and  the  phrase  discarded,  as  the  patient 
will  not  know  whether  he  is  desired  to  throw  the  whole 
upper  thorax  back,  or  to  approximate  the  scapulas.  The 
former  is  the  movement  usually  executed,  and  is,  of 
course,  noxious  to  posture.  The  command  should  be 
"  bring  your  shoulder-blades  together,"  if  this  movement 
is  desired,  and  the  trainer  must  see  to  it  that  this  is 
done  with  the  upper  chest  high  and  forward,  and  with 
a  straight  spine  slightly  inclined  forward.  When  accom- 
panied by  a  resistant  round  back,  this  will  frequently 
need  correcting  and  strengthening  exercises,  and  occa- 
sionally corrective  corsets  or  braces.  Corrective  exer- 
cises should  always  be  added  to  mechanical  treatment. 
(See  Round  Back.) 

One  prominent  scapula  is  usually  secondary  to  a  dorsal 
rotary  lateral  curvature.  The  scapula  and  shoulder  are 
elevated  and  prominent  on  the  side  of  the  dorsal  con- 
vexity ;  that  is,  the  side  toward  which  the  rotation  takes 


SHOULDEE 


211 


place,  and  on  which  the  angles  of  the  ribs  are  prominent. 
The  scapula  and  shoulder  are  low  and  flattened  on  the 
concave  side  of  the  scoliosis.  The  treatment  of  the  lat- 
eral curvature  corrects  or  improves  the  posture  of  the 
shoulders.  Prominent  scapulae  may  accompany  round 
back. 

A  winged  scapula  is  one  whose  posterior  border  and 
inferior  angle  are  prominent  from  paralysis  of  the  ser- 
ratus  magnus. 

Acute  osteomyelitis  of  the  scapula  may  occur,  and  may 
require  partial  or  total  excision.  If  done  subperiosteally 
the  scapula  may  reform. 

Exostoses  occasionally  require  removal. 

Shoulder 

Congenital  ankylosis  of  the  shoulder  is  very  rare. 
In  a  case  of  congenital  axillary  web  preventing  free 
arm  abduction,  the  writer  made  incisions  as  shown  in 


L 


a 


J 


a 


b 
A 


B 


Fig.  112. — A.  Incisions  for  Axillary  Web;  the  Fold  is  Narrowed  and 
Lengthened.  B.  Lengthening  May  be  Accomplished  with  Less 
Narrowing  by  the  Z-shaped  Incision,  with  Dissection  of  the  Flaps. 
(McCurdy.) 

the  cut  (Fig.  112),  excised  the  limiting  bands,  allowed 
the  end  flaps  {a  a)  to  retract,  and  brought  the  side  flaps 
{h  h)  together.    The  result  was  excellent. 


212     DEFORMITIES    OF    SHOULDER-GIRDLE 


So-called  congenital  dislocation  of  the  shoulder  is  also 
rare.  What  usually  goes  under  this  name  is  a  displace- 
ment secondary  to  brachial  plexus  palsy. 

Birth  palsy  is  due  to  stretching  or  rupture,  during 
delivery,  of  one  or  more  of  the  cords  of  the  brachial 

plexus,  usually  the 
one  formed  by  the 
■anion  of  the  fifth 
and  sixth  cervical 
nerves  (Fig.  113). 
There  is  usually  a 
history  of  difficult 
labor  and  instru- 
mental delivery  or 
manual  traction. 
The  baby's  arm,  in 
the  usual  type,  is 
helpless  at  the 
shoulder,  and  often 
at  the  elbow,  but 
the  hand  and  fingers 
can  be  moved.  The 
arm  hangs  by  the 
side  with  the  hand 
pronated.  If  the 
lower  cords  of  the 
plexus  are  involved, 
the  hand  is  also  par- 
alyzed. There  may  be  some  improvement,  but  there  is 
usually  considerable  permanent  disability,  most  severe 
at  the  shoulder,  which  may  become  partially  fixed  from 


Fig.  113.  —  Obstetric  Palsy  with  Frac- 
ture OF  Scapula;  Infant  Three  Months 
Old. 


SHOULDER  213 

adaptive  shortening  of  the  adductors  and  subluxated 
from  continuous  pressure  on  the  capsule.  The  progno- 
sis as  to  complete  recovery  is  bad.  The  treatment  is  a 
sling  at  first,  to  relax  stretched  muscles  and  to  correct 
deformity,  passive  motion  after  recovery  from  the  in- 
jury, and  motor  education  in  the  use  of  the  hand  and 
arm  in  grasping,  feeding,  and  putting  on  clothes.  Forci- 
ble correction  of  displacement,  or  to  obtain  better  pos- 
tures and  to  increase  motion,  or  surgical  interference, 
may  be  indicated  in  special  cases.  Suture  of  the  brachial 
plexus  has  been  done;  the  results,  while  somewhat  en- 
couraging, seem  of  rather  slight  practical  value.  Similar 
palsies  occur  in  children  and  adults  from  dislocation  of 
the  shoulder  and  other  injuries. 

Dangle  shoulder  usually  occurs  in  an  arm  atrophied 
from  a  previous  attack  of  poliomyelitis.  Muscular  sup- 
port being  gone,  the  weight  of  the  arm  stretches  the 
capsular  ligaments,  and  drags  the  humerus  away  from 
the  glenoid  cavity.  In  such  a  case  all  the  parts  in  and 
about  the  shoulder- joint,  including  the  shoulder-girdle 
and  arm  bones,  are  much  atrophied,  and  the  deltoid  and 
external  rotators  are  practically  destroyed.  If  the  mus- 
cles which  move  the  scapula  are  still  intact,  something 
may  be  done  by  an  arthrodesis  at  the  shoulder-joint  so 
that  the  humerus  may  be  moved  with  the  scapula.  If 
the  trapezius  is  intact,  its  anterior  border  may  be  sepa- 
rated and  transplanted  into  the  humerus  to  take  the 
place  of  the  deltoid,  or  a  strip  from  the  pectoralis  major 
may  be  attached  to  the  trapezius.  Owing  to  the  extent 
of  the  palsy  the  result  of  these  operations  is  usually 
mediocre. 


214     DEFORMITIES    OF    SHOULDER-GIRDLE 

Traumatic  Conditions. — Dislocations  of  the  head  of  the 
humerus  and  other  injuries  are  often  followed  by  a  cir- 
cumflex neuritis  or  palsy,  with  pain  and  weakness  of  the 
deltoid.  Stiffness  often  follows  fractures  and  other  in- 
juries near  the  shoulder,  partly  due  to  adhesions  or  thick- 
ening about  the  joint,  but  frequently  to  adaptive  short- 
ening of  the  anterior  and  posterior  muscles  which  hold 
the  arm  to  the  side  (adductors),  with  atrophy  of  most 
of  the  muscles  which  move  the  shoulder.  It  is  sometimes 
difficult  to  decide,  without  an  X-ray  or  narcosis,  whether 
bony  ankylosis  is  present.  After  recovery,  massage,  vi- 
bration, and  passive  motion  are  valuable  to  restore  mus- 
cle tone  and  increase  motion.  Narcosis  and  forcible 
manipulation,  taking  care  to  fix  the  scapula,  are  some- 
times indicated.  One  should  not  attempt  to  do  too  much 
at  one  sitting,  lest  the  reaction  do  more  damage  than  the 
mobilization  does  good.  Active  shoulder  movements  and 
creeping  up  the  wall  with  the  fingers  may  be  beneficial 
afterwards.  The  use  of  light  chest  weights  or  pulley 
devices,  and  of  the  wand  grasped  by  both  hands,  is  often 
useful;  also  hanging  from  the  trapeze,  with  the  feet  on 
the  floor. 

Recurrent  Dislocation  of  the  Shoulder. — It  sometimes  hap- 
pens that  the  capsule  of  the  shoulder-joint  becomes  loose 
after  a  dislocation,  and  that  a  slight  movement  of  the 
kind  which  produced  the  original  luxation  will  throw  it 
out  again.  After  several  repetitions  the  shoulder  is  very 
readily  displaced.  A  shoulder  cap  may  be  fitted  to  the 
shoulder  and  upper  arm,  and  attached  by  straps  under 
the  opposite  axilla.  This  prevents  abduction  of  the  arm, 
and  allows  the  stretched  parts  to  shrink.    Goldthwait  has 


SHOULDER  215 

pointed  out  that  shoulder  movements  are  much  more  ex- 
tensive in  the  forward  or  drooped  posture;  he  recom- 
mends holding  the  shoulders  back  by  an  appliance  in 
recurrent  dislocations.  When  such  means  are  insufficient 
the  capsule  may  be  tightened  by  excision  of  the  redundant 
part,  as  in 

Bukeell's  Operation  for  Recurrent  Dislocation 
OP  the  Shoulder 

"  The  following  technic  is  slightly  modified  from  that 
of  Burrell  and  Lovett.  An  incision  is  made  from  the 
coracoid  process  downward  and  outward,  following  the 
line  of  the  cephalic  vein  to  about  the  insertion  of  the 
deltoid  muscle.  The  cephalic  vein  is  drawn  inward,  and 
the  intermuscular  septum  between  the  deltoid  and  pec- 
toralis  major  is  recognized  and  those  two  muscles  sepa- 
rated by  blunt  dissection.  The  coraco-brachialis  and 
short  head  of  the  biceps  come  into  view  in  the  upper  end 
of  the  wound,  and  the  insertion  of  the  pectoralis  major 
in  the  lower  angle  of  the  wound.  The  head  and  neck  of 
the  bone  is  then  exposed  by  thorough  blunt  dissection. 
In  order  to  do  this  it  is  necessary  to  carry  the  incision 
in  its  whole  depth  up  to  the  coracoid  process,  and  free 
carefully  the  tendons  of  the  coraco-brachialis  and  short 
head  of  the  biceps  quite  up  to  their  origin  on  the  coracoid 
process.  The  anterior  and  inferior  aspects  of  the  capsule 
are  then  exposed  by  developing  the  pectoralis  major  and 
latissimus  dorsi  and  retracting  them  downward,  and  by 
dividing  a  portion  of  the  subcapularis  muscle  and  re- 
tracting it  upward  (Fig.  114).  The  arm  should  then  be 
abducted  from  the  body  about  thirty  degrees.    This  pos- 


216     DEFORMITIES    OF    SHOULDER-GIRDLE 

ture  allows  the  best  exposure  as  well  as  best  relaxation 
of  the  capsule.  The  loose  part  of  the  front  and  inferior 
aspect  of  the  capsule  is  then  grasped  with  three  hemo- 


FiG.  114. — Burrell's  Operation  for  Recurrent  Dislocation  of  the 
Shoulder.  A,  Pectoralis  minor;  B,  coraco-brachialis ;  C,  subscapularis; 
D,  humerus;  E,  pectoralis  major  and  latissimus  dorsi;  F,  deltoid;  G,  lower 
part  of  capsule;  H,  coracoid  process.  {Albee  in  American  Journal  of 
Surgery.) 

stats.    Three  sutures  of  No.  1  chromic  catgut  are  inserted 
with  a  curved  needle  beneath  this  fold  of  the  capsule, 


SHOULDER  217 

from  which  an  elliptical  piece  one  inch  long  and  one  half 
inch  wide  is  excised  between  the  placed  sutures.  When 
these  sutures  are  tightened  and  tied  it  will  be  found  that 
the  capsule  is  distinctly  shorter. 

"  A  broad  retractor  without  sharp  points,  to  retract 
the  coraco-brachialis  muscle  and  vessels  inward,  is  a 
great  help.  "When  the  arm  is  brought  to  the  side  all  the 
structures  fall  into  place,  and  it  is  only  necessary  to 
suture  the  superficial  fascia  and  skin.  The  arm  should 
be  held  to  the  side  with  a  plaster  shoulder  cap  and  a 
tight  sling  over  elbow  and  forearm,  to  remove  the  weight 
of  arm  from  the  sutures,  and  should  be  retained  in  this 
splint  for  two  weeks,  when  the  plaster  is  removed  and 
moderate  passive  movements  begun.  At  the  end  of 
three  weeks  the  sling  should  be  discarded  also,  and  both 
active  and  passive  exercises  begun.  In  five  weeks  the 
patient  will  usually  be  able  to  return  to  work"  (Albee). 

Isolated  fracture  of  the  greater  tuberosity  of  the  humerus 
is  a  rare  accident  from  a  fall  on  the  shoulder  or  hand 
(Figs.  115  and  116).  It  is  followed  by  a  great  deal  of 
ecchymosis  down  the  arm.  Displacement  is  ordinarily 
not  great,  and  a  good  result  is  obtained  by  simple  im- 
mobilization of  the  shoulder  in  a  sling  or  halter. 

Juxta-epiphyseal  fracture  of  the  upper  end  of  the  humerus 
occurs  of tenest  from  the  tenth  to  the  twentieth  year.  The 
upper  epiphysis  includes  the  head  and  both  tuberosities, 
and  these  fractures  are  situated  between  the  anatomical 
and  surgical  neck,  and  may  be  mistaken  for  a  fracture 
of  either  or  for  dislocation  at  the  shoulder,  on  account 
of  the  rounded  upper  end  of  the  lower  fragment.  This 
is  a  difficult  fracture  to  treat  by  the  usual  methods,  and 

16 


218     DEFORMITIES    OF    SHOULDER-GIEDLE 

even  if  reduction  is  accomplished  there  is  a  strong  tend- 
ency to  displacement.  On  account  of  the  action  of  the 
muscles  inserted  into  the  tuberosities  the  fractured  sur- 
face of  the  upper  fragment  is  rolled  upward  and  for- 
ward until  further  elevation  is  prevented  by  the  imping- 
ing of  the  greater  tuberosity  on  the  acromion.  This  was 
observed  by  Albee  in  May,  1906,  wliile  operating  on  a 


Fig.  115. — Isolated  Fracture  of  Greater  Tuberosity  of  the  Humerus 
FROM  Fall  on  Tip  of  Shoulder  ;  Man  of  Forty-six.  (Skiagram  taken 
at  Roosevelt  Hospital  four  days  after  the  accident.) 

fracture  of  this  type.  As  it  was  found  difficult  to  roll 
the  upper  fragment  downward,  the  lower  fragment  was 
aligned  with  it  in  an  anterior  horizontal  position,  slightly 


SHOULDER 


219 


rotated  inward,  and  with  tlie  elbow  flexed  at  a  right 
angle.  The  arm  and  shoulder  were  held  in  place  by  a 
plaster  spica  reaching  from  the  wrist  to  the  waist  (Fig. 


Fig.  116. — Same  Shoulder  Three  and  a  Half  Years  Later,  Showing 
Bony  Union.  The  only  treatment  was  support  in  a  sling;  function  is 
perfect. 


117).  In  this  and  a  subsequent  case  the  fragments  have 
been  easily  held  and  the  results  excellent.  The  last  pa- 
tient won  a  swimming  competition  three  months  after 
the  reduction  (Albee). 

Bursitis. — The  subdeltoid  bursa  is  as  large  as  the  palm 
of  the  hand  (Codman),  and  is  spread  over  the  shoulder 
like  an  epaulet.     There  is  a  bursa  under  the  acromion 


220     DEFORMITIES    OF    SHOULDER-GIRDLE 

which  may  connect  with  it.     The  subdeltoid  bursa  may 
become  inflamed  after  injury  or  infection,  causing  pain 


Fig.  117.  —  Albee's   Posture   for   Juxta-epiphyseal  Fracture   op  the 
Upper  End  of  the  Humerus.     (From  The  Post  Graduate,  June,  1908.) 


SHOULDER  221 

and  swelling  over  the  top  of  the  shoulder  and  restrict- 
ing motion.  In  its  active  stage  rest  and  counter-irrita- 
tion by  iodin  is  indicated.  The  arm  should  be  kept 
abducted.  To  combat  the  subsequent  stiffness  forcible 
manipulation  may  be  needed,  though  many  cases  yield 
to  vibration  and  passive  and  active  movements.  In 
obstinate  cases  the  bursa  may  rarely  be  opened  and 
cleared  of  adhesions  through  an  open  incision  (Cod- 
man),  or  it  may  be  excised  (Baer).  The  subacromial 
bursa  may  become  inflamed  from  the  pressure  and  rub- 
bing of  the  tuberosity  of  the  humerus  in  the  droop- 
shoulder  posture.  This  may  give  rise  to  pain  and  dis- 
ability, and  may  be  relieved  by  holding  the  shoulders 
back  by  a  back  brace  or  shoulder  straps  (Goldthwait). 

Ii^FECTioNs  AND  Teophic  Changes.  —  The  shoulder 
may  be  infected  by  pus  cocci,  gonococci,  syphilitic  and 
tuberculous  microbes,  and  may  be  the  seat  of  "  rheu- 
matoid "  affections.  The  treatment  is  the  treatment  of 
the  primary  condition,  and  immobilization  of  the  shoul- 
der. The  latter  is  often  sufficiently  accomplished  by  the 
Thomas  wrist  halter,  by  which  the  wrist  is  elevated  and 
suspended  from  the  neck.  Pus  joints  require  incision. 
Arthritis  deformans  of  the  shoulder  may  come  on  slowly 
or  rapidly  without  known  cause,  or  after  an  injury. 
There  are  pain  and  increasing  stiffness  and  more  or 
less  grating,  but  no  tendency  to  suppuration.  The  treat- 
ment is  rest,  if  symptoms  are  acute,  passive  movements, 
vibration,  and  measures  to  increase  local  circulation  and 
nutrition  in  the  inactive  stage. 

Fibrous  Ankylosis. — In  the  stiffness  following  shoulder 
inflammations,  one  should  be  careful  not  to  begin  painful 


222     DEFORMITIES    OF   UPPER   EXTREMITY 

movements  too  early  or  to  push  them  too  far  or  too 
rapidly.  When  the  joint  becomes  stiffer  after  exercise 
or  manipulation  these  should  be  interrupted  or  reduced, 
as  harm  is  being  done.  Exercises  similar  to  those  rec- 
ommended in  the  first  part  of  this  section  are  often 
useful.  Forcible  manipulation  under  ether  is  sometimes 
required. 

THE  ARM 

Deformities  of  the  Shaft  of  the  Humeeus 

The  humerus  may  be  congenitally  short  or  wholly  or 
partially  absent  (phocomelia).  Deformities  from  badly 
united  fractures  may  require  manual  or  instrumental 
correction  (Thomas  wrench)  within  a  few  weeks  of  the 
injury,  osteotomy  if  older. 

Deformities  of  the  Elbow 

Congenital  luxations  of  the  proximal  end  of  the  radius 
may  occur  forward,  backward,  or  outward,  and  are  occa- 
sionally bilateral.  Luxation  of  both  bones  of  the  fore- 
arm is  rare,  and  of  the  ulna  alone  unknown.  Motion  at 
the  elbow  is  diminished,  the  ends  of  the  bones  may  be 
deformed,  and  growth  impeded.  In  early  cases,  reposi- 
tions may  be  attempted.  Function  will  usually  be  im- 
proved in  the  older  cases  by  excision  of  the  head,  and 
sometimes  of  a  portion  of  the  shaft  of  the  radius. 

Congenital  stiffness  of  the  elbow  is  rare.  Abnormal  loose- 
ness, especially  in  hyperextension,  is  more  frequent.  In 
cubitus  valgus  the  forearm  deviates  outward  (radialward), 
in  cubitus  varus  toward  the  body  (ulnaward).  The  lat- 
ter is  common  after  fractures  of  the  internal  condyle, 


THE   ELBOW 


223 


and  may  be  corrected  by  an  osteotomy  above  the  elbow. 
According  to  Thomas,  fractures  about  the  elbow,  except 
fractures  of  the  olecranon,  should  be  treated  with  the 


Fig.  118. — Detachment  of  External  Condyle  Producing  a  Straight 
Arm  with  Very  Little  Motion;  Boy  of  Four.  Removal  of  fragment 
by  Albee  eight  weeks  later;  result,  perfect  motion. 


elbow  j9exed  beyond  a  right  angle.  If  stiffness  should 
result,  this  is  the  most  useful  posture.  Some  authorities, 
however,  report  excellent  results  in  condylar  fractures 
from  splinting  in  the  extended  posture  if  the  fragments 


224     DEFORMITIES    OF    UPPEE   EXTREMITY 

are  first  carefully  reduced  and  maintained.  Injuries 
about  the  elbow  may  be  followed  by  osteomata  interfer- 
ing with  motion,  which  may  require  removal,  as  do  some- 
times displaced  fragments  of  bone  (Fig.  118),  exuberant 
callus,  and  floating  bodies,  broken  from  the  olecranon 
or  coracoid  process. 

Bursitis. — There  are  some  fifteen  bursse  about  the  el- 
bow, several  of  which  are  clinically  important.  The 
subtendinea  and  intratendinea  olecrani  may  become 
irritated  after  heavy  work,  also  in  lawn-tennis  players 
(Lloyd) ;  they  are  also  liable  to  tuberculous  and  other 
infections,  when  the  olecranon  may  become  secondarily 
diseased.  The  radio-bicipitalis  bursa  may  become  irri- 
tated in  golf  players  (Lloyd)  and  others,  giving  rise  to 
a  tender,  elastic  swelling  in  front  of  the  radius  near  the 
iQsertion  of  the  biceps. 

Rest,  counter-irritation,  and  pressure  are  usually 
curative  in  simple  bursitis.  In  tuberculous  or  pus  in- 
fections the  bursa  should  be  opened  and  scraped  out, 
with  adjacent  diseased  tissue. 

Infections  of  the  elbow-joint  are  treated  as  elsewhere  by 
incision  and  drainage  if  purulent,  by  immobilization  if 
tuberculous  (Fig.  119),  by  massage,  douching,  and  elec- 
tricity if  "  rheumatoid."  Inflammations  of  the  elbow, 
wrist,  hand,  and  even  of  the  shoulder,  may  be  treated 
by  Bier's  method  of  venous  congestion.  Molded  or  cir- 
cular plaster  splints  may  be  used  for  immobilization, 
or  the  wrist  halter  may  be  used,  or  the  sleeve  pinned  up 
with  a  safety  pin.  Excision  is  occasionally  useful  to 
remove  extensive  disease,  or  to  mobilize  an  elbow  anky- 
losed  in  a  bad  posture.    The  result  is  usually  a  movable, 


THE    ELBOW 


225 


and  sometimes  a  flail,  joint.    Murphy  reports  good  results 
from  arthroplasty. 

In  the  cured  cases  measures  to  improve  local  nutrition 
and  judicious  active  and  passive  movements  to  increase 
mobility  are  of  use. 
Operations  to  over- 
come a  moderate  de- 
gree of  flexion  are 
not  indicated,  since 
this  does  not  inter- 
fere with  practically 
full  use  of  the  arm. 
Jones  cuts  out  a 
large  diamond  from 
the  skin  at  the  bend 
of  the  elbow,  and 
sews  the  upper  and 
lower  halves  to- 
gether in  order  to 
hold  a  paralyzed  and 
loose  elbow  in  the 
flexed  position,  so 
that  the  hand  may 
still  be  used. 

Persistent  prona- 
tion from  overaction 
of  the  pronators  af- 
ter paralysis  of  the 
supinators  in  obstet- 
ric and  other  forms  of  arm  palsy  may  be  obviated  by 
dissecting  the  pronator  teres  loose  from  its  origin  on  the 


Fig.  119. — Tuberculous  Elbow  with 

Sinus. 


226    DEFOEMITIES    OF    UPPER    EXTREMITY 

internal  condyle  and  neighboring  parts  and  suturing  it 
to  the  external  condyle  (Hoffa).  Its  action  may  also  be 
reversed  by  detaching  its  insertion  from  the  radius,  pass- 
ing it  through  the  interosseous  septum,  and  again  attach- 
ing it  to  the  radius. 

Defoemities  of  the  Foreaem 

Congenital  Deformities. — Absence  of  the  ulna  is  rare. 
Absence  of  the  radius,  complete  or  partial,  on  one  or 
both  sides,  is  occasionally  seen  (Fig.  120).  In  the  latter 
condition  the  ulna  is  short  and  bent,  the  hand  deviates 


Fig.  120. — Absence  of  Radius,  Both  Sides;  Girl  Fifteen  Months  Old. 
(Skiagram  by  Martin.) 

to  the  radial  side,  and  one  or  more  digits  may  be  absent 
from  the  radial  side  of  the  hand.  In  spite  of  the  severe 
deformity,  these  persons  sometimes  use  the  hands  so 
skillfully  that  it  is  doubtful  if  the  condition  is  much  im- 


THE   WRIST    AND   HAND  227 

proved  by  implanting  the  ulna  into  the  carpus,  as  has 
been  done. 

Deformation  of  the  forearm  after  fractures  may  require 
correction.  In  the  green-stick  fracture  of  children  the 
necessary  correction  may  be  made  with  the  hands.  De- 
formity after  Colles's  fracture,  if  not  too  old,  may  be 
adjusted  by  the  hand  or  by  the  Thomas  wrench;  in  old 
cases  by  an  osteotomy. 

Mamis  valga  or  vara  may  be  produced  by  bending  or 
unequal  growth  of  one  of  the  bones  of  the  forearm 
from  rickets,  osteomyelitis,  fractures,  osteochondroma- 
ta,  and  other  causes.  Osteotomy  or  the  excision  of 
a  piece  of  the  longer  bone  is  sometimes  indicated  to 
correct  the  deformity. 

Deformities  of  the  Weist  and  Hand 

In  the  lobster-claw  deformity  there  are  two  large  digits 
and  the  hand  is  split.  Certain  carpal  and  metacarpal 
bones  and  digits  may  be  absent  when  the  radius  or  ulna 
is  deficient ;  the  hand  is  bent  toward  the  side  of  the  miss- 
ing bone. 

Congenital  dislocation  of  the  hand  forward  or  backward 
is  a  rare  condition. 

Congenital  club-hand  corresponds  to  club-foot,  and  some- 
times accompanies  it,  but  is  much  rarer.  The  deflection 
may  be  dorsal,  palmar,  radial,  or  ulnar.  It  is  due  to 
the  pressure  of  the  uterine  walls.  Gradual  correction  by 
aluminium,  plaster,  or  other  splints  is  usually  possible. 
Some  forms  of  club-hand  are  due  to  absence  of  the 
radius  or  ulna. 


228    DEFORMITIES    OF    UPPER    EXTREMITY 

Spontaneous  subluxation  of  the  hand  forward  is  an  un- 
usual deformity  occurring  most  fi^equently  in  girls  who 
work  hard  with  the  wrist  flexed,  particularly  washer- 
women; it  may  be  unilateral  or  bilateral,  and  may  rest 


Fig.  121. — Dislocation  of  Hands  Forward  Both  Sides;  Girl  of  Eighteen; 
Older  Sister  has  Same  Deformity. 

on  a  congenital  basis  (Fig.  121).  There  is  a  change  in 
the  plane  of  the  radio-carpal  joint,  caused  by  absorption 
at  the  volar  edge,  and  by  curvature  of  the  lower  end 
of  the  radius  with  volar  concavity.  The  wrist  is  broad- 
ened, and  the  distal  epiphyses  of  the  radius  and  ulna 
are  prominent  at  the  back  of  the  wrist.  The  hand  is 
displaced  forward,  and  often  deviates  laterally ;  the  flexor 
tendons  are  prominent.  Wrist  extension  is  limited,  and 
often  painful.  At  the  beginning  of  the  process  heavy 
wrist  work  should  be  interdicted,  and  the  wrist  put  at  rest 
by  strapping  or  a  light  splint.  In  advanced  cases  the  wrist 
may  be  manipulated  and  put  up  in  moderate  extension. 


THE    WRIST   AND   HAND 


229 


Obstinate  cases  may  be  corrected  by  osteotomy  of  the 
radius  or  readjustment  at  the  proximal  carpal  joint. 

In  spastic  palsies  and  hemiplegia  the  elbow  and  hand  are 
often  flexed  and  the  hand  deviated  to  the  ulnar  side.  In 
paralysis  of  the  extensors  the  hand  drops  into  the  pos- 
ture of  flexion,  and  there  is  often  accommodation  short- 
ening of  the  flexor  muscles  and  ligaments,  preventing 


Fig.  122. — Aluminium  Wrist  and  Hand  Splint;  the  Patient  has  Tuber- 
culosis OF  THE  Wrist. 

passive  correction.  The  flexed  position  at  the  wrist  ren- 
ders the  hand  almost  useless,  as  the  flexors  cannot  be 
used  in  this  posture.     Stretching  and  splinting  by  the 


230    DEFOEMITIES    OF    UPPEE    EXTREMITY 

cockup  (Thomas)  splint  (Fig.  122)  may  correct  this  de- 
formity, and  if  the  paralysis  is  temporary  the  extensor 
muscles  may  regain  their  tone.  In  other  cases  it  may  be 
necessary  to  divide  the  palmaris  longus,  and  to  lengthen 
the  carpal  flexors.  The  extensors  may  also  be  shortened. 
In  not  too  severe  cases  with  flexion  and  ulnar  devia- 
tion an  excellent  result  may  be  obtained  by  shortening 
the  radial  extensors  of  the  carpus,  and  splinting  the 
hand  in  the  overcorrected  posture.  In  cases  of  per- 
manent palsy  of  the  extensors  with  carpal  flexion,  one 
or  more  of  the  superficial  flexors  may  be  brought 
through  the  interosseous  space,  and  stitched  to  the 
extensor  tendons.  Improved  posture  is  usually  secured, 
but  the  functional  results  of  this  operation  are  not  very 
brilliant. 

Volkmann's  Ischemic  Palsy. — The  pressure  of  splints  or 
constricting  bands  may  be  followed  by  nerve  lesions  and 
fibrous  degeneration  of  the  muscles  near  the  site  of  the 
injury.  Permanent  paralysis  with  flexion  of  the  wrist 
and  fingers  of  severe  grade  (claw-hand)  may  result  (Fig. 
123).  Operations  to  free  the  nerves  from  their  fibrous 
envelope  are  sometimes  indicated,  but  are  complicated  in 
many  instances  by  the  degeneration  of  the  muscles  them- 
selves. Tenotomies  and  lengthening  of  the  shortened 
tendons  and  even  excision  of  one  or  two  inches  of  the 
shafts  of  the  radius  and  ulna  have  been  done  to  correct 
the  deformity,  but  the  ingenious  method  of  splinting  in 
stages  advised  by  Robert  Jones  makes  such  operations 
unnecessary.  With  the  wrist  fully  flexed  small  splints 
are  first  applied  to  the  palmar  surfaces  of  the  fingers ; 
after  these  are  straightened  the  fingers  and  metacarpus 


THE   WEIST   AND   HAND  231 

are  splinted  and  only  after  the  hand  and  fingers  are 
straight  is  the  wrist  attacked  by  a  long  palmar  splint. 
This  method  has  recently  proved  entirely  successful  in 


Fig.  123. — Ischemic  Palsy  Following  Tight  Dressings  for  Fracture 
Involving  the  Elbow. 


an  obstinate  case  of  the  writer's  who  used  a  splint  of 
aluminium  made  from  tracing  the  hand  with  slightly 
spread  fingers.     This  was  bent  to  the  deformity,  each 


232    DEFOEMITIES    OF    UPPER    EXTREMITY 

finger  strapped  to  its  splint  with  adhesive  plaster,  and 
the  hand  plate  held  in  place  by  a  strap  over  the  dor- 
sum. The  finger  pieces  were  gradually  straightened, 
then  the  metacarpo-phalangeal  region,  the  correction 
taking  only  a  few  days.  Then  an  arm  splint  was  riv- 
eted to  the  hand  piece  and  the  wrist  forced  down  by  a 
strap. 

Ganglia  of  the  wrist  due  to  local  collections  of  gelatinous 
fluid  in  a  dilated  bit  of  tendon  sheath  may  be  dissipated 
by  rupture  followed  by  local  pressure.  If  on  the  dorsal 
aspect,  the  part  is  made  tense  by  flexing  the  wrist  and 
sharply  struck  with  a  book.  A  covered  coin  or  wooden 
button  is  then  placed  over  the  part,  fastened  by  adhe- 
sive plaster,  and  allowed  to  remain  three  weeks  to 
prevent  reaccumulation.  Tuberculous  and  other  intract- 
able forms  of  bursitis  will  require  extirpation.  Small 
fatty  tumors,  simulating  ganglia,  occasionally  occur 
near  the  tendons  of  the  fingers  and  wrist,  and  should 
be  excised. 

Disease  at  the  wrist- joint  is  treated  on  the  same  princi- 
ples as  at  other  joints ;  blennorrhagic  involvement  is  not 
rare.  Tuberculous  infection  requires  prolonged  fixation, 
but  this  joint,  as  well  as  the  elbow,  is  suitable  for  the 
Bier  congestion  treatment.  Mobilization  of  stiffened 
joints  after  the  subsidence  of  operation  is  effected  by 
vibration,  massage,  baking,  electricity,  and  active  and 
passive  movements.  If  there  is  bony  ankylosis  with  the 
wrist  flexed,  excision  of  the  carpus  or  other  bone  opera- 
tion may  be  indicated  to  correct  the  deformity;  here, 
as  in  many  locations,  a  deformed  joint  is  worse  than  a 
stiff  one. 


THE    FINGERS 


233 


Defoemities  of  the  Fingees 

Redundant  fingers  {polydactylism)  or  parts  of  fingers 
should  be  removed  during  the  second  year. 

Congenital  absence  of  one  or  more  fingers  is  usually  as- 
sociated with  partial  or  complete  absence  of  one  of  the 
bones  of  the  forearm.  The  absent  fingers  are  always  on 
the  side  of  the  defective  bone.  Fusion  of  fingers  may 
occur. 


Fig.  124. — Congenital,  Web  Fingers,  Left  Hand. 


Congenital  webs  of  the  fingers  {syndactylism)  (Fig.  124) 
occasionally  occur,  and,  like  acquired  webs  from  burns 


17 


234    DEFORMITIES    OF    UPPER    EXTREMITY 

or  other  causes,  require  a  plastic  operation  to  separate 
the  fingers. 

Congenital  deviations  of  one  or  more  end  phalanges  to 
the  radial  or  ulnar  side  are  occasionally  seen,  and  may 
be  corrected  by  small  aluminium  splints  and  adhesive 
plaster.  The  small  finger  may  also  be  flexed.  Both  these 
deformities  are  hereditary  in  certain  families.  The  flex- 
ion deformity  may  be  corrected  by  a  small  padded  splint 
of  aluminium  or  other  material,  fixed  in  place  by  adhesive 
plaster.  It  may  be  shaped  to  the  deformity  at  first,  and 
gradually  straightened. 

Drop  phalangette  (Stern),  or  mallet-finger  (Fig.  125), 
is  due  to  a  complete  or  partial  rupture  of  the  extensor 
tendon  near  its  insertion  into  the  base  of  the  end  pha- 
lanx. It  may  be  produced  by  a  blow  on  the  end  of 
the  finger  or  by  a  forced  flexion  while  the  extensor  is 
tense. 

In  recent  cases  the  end  phalanx  should  be  forced  into 
hyperextension  by  a  small  palmar  splint,  and  the  wrist 
and  finger  kept  in  extension  to  relax  the  tendon.  In  old 
cases,  or  where  splinting  has  failed,  the  tendon  should 
be  attached  to  its  insertion  by  a  suture. 

Stiffness  of  the  fingers,  either  extended  or  flexed,  the 
result  of  inflammation  in  the  forearm,  wrist,  or  hand, 
or  in  the  finger-joints,  is  common,  and  is  often  combined 
with  wrist  stiffness.  Very  much  can  be  done  by  per- 
sistence and  thoroughness  in  many  of  these  distressing 
cases.  Baking,  vibration,  massage,  electricity,  and  active 
and  passive  movements  of  the  hand  and  arm  are  of 
great  value  after  subsidence  of  inflammation.  Indeed, 
it  is  possible  in  some  severe  cases  to  effect  a  cure.  Flexed 


THE    FINGERS 


235 


fingers  may  be  straightened  by  splints,  and  the  straight 
fingers  may  be  flexed  by  a  stout  glove,  which  carries 
tapes  at  the  ends  of  the  fingers,  which  are  drawn  through 


Fig.  125. — Aluminium  Splint  for  Drop  Phalangette. 


rings  fastened  near  the  wrist  (Krukenberg).  Simply 
bandaging  the  fingers  over  a  wad  of  cotton  or  a  ball  of 
yarn  may  be  effective. 

Dupuytren's  contraction  of  the  fing-ers  occurs  most  fre- 
quently in  middle-aged  men  (Fig.  126).  It  is  caused  by 
a  slow  inflammation  and  contraction  of  fibrous  bands 
of  the  palmar  fascia  due  to  gout,  diabetes,  tabes,  or 


236    DEFORMITIES    OF    UPPER    EXTREMITY 

trauma,  especially  slight  trauma  frequently  repeated,  as 
in  hard  work  with  hand  tools.  Permanent  flexion  of  one 
or  more  fingers  results.  The  treatment  is  multiple  sub- 
cutaneous section  of  the  contracted  bands,  or  their  com- 


FiG.   126. — Dupuytren's  Contraction;  Ring  Finger.     (Phelps.) 


plete  excision,  through  open  cuts,  followed  by  correction 
and  retention  in  the  extended  posture  for  two  or  three 
weeks.  This  is  to  be  followed  by  massage  and  move- 
ments. 

Krukenberg's  finger  deformity  is  a  flexion  deformity  of 
the  fingers  with  ulnar  deviation  and  luxation  of  the  ex- 
tensor tendon  into  the  metacarpal  space.    This  deform- 


THE    FINGERS  237 

ity  occurs  as  a  complication  of  arthritis  deformans. 
When  the  luxated  extensor  contracts  the  two  distal 
phalanges  are  extended  and  the  proximal  is  flexed. 
It  is  sometimes  advisable,  if  joint  function  is  good,  to 
cut  a  groove  in  the  metacarpal  head  and  replace  the 
tendon. 

In  trigger-finger  there  is  an  obstruction  at  some  point 
in  flexion  or  extension,  which  is  overcome  with  effort. 
When  it  is  overcome  the  movement  is  suddenly  completed 
with  a  jerk.  This  phenomenon  is  due  to  a  thickening 
near  one  of  the  joints  or  in  the  tendon  or  tendon  sheath, 
which  may  be  due  to  injury,  arthritis  deformans,  or 
certain  occupations.  It  may  in  mild  cases  disappear 
spontaneously;  other  cases  may  be  cured  by  wet  com- 
presses, vibration,  massage,  and  movements,  while 
obstinate  cases  can  only  be  cured  by  removing  the 
obstruction. 

Professional  Cramps. — Writers',  pianists',  violinists',  te- 
legraphers', and  seamstresses'  cramps  are  characterized 
by  incoordination,  pain,  and  weakness  or  spasm  of  the 
muscles  of  the  forearm  and  hand,  which  have  been 
habitually  overworked,  particularly  by  long-continued, 
finely  adjusted  movements.  The  pains  and  cramps  are 
often  so  severe  that  the  occupation  causing  them  has 
to  be  given  up.  Spastic,  paralytic,  or  tremulous  symp- 
toms may  predominate.  Delicate  and  neurotic  people 
are  most  subject  to  these  affections.  Treatment  is  often 
difficult  and  usually  prolonged,  but  frequently  success- 
ful. The  occupation  causing  the  cramp  must  be  given 
up  until  the  cure  is  complete,  or  nearly  so.  Massage  or 
vibration  of  the  arm  and  upper  spine,  galvanization,  and 


238    DEFORMITIES    OF    UPPER    EXTREMITY 

muscle  training,  especially  in  the  larger  movements  with 
tonic  treatment,  usually  give  satisfactory  results.  In 
writers'  cramp  the  use  of  the  typewriter  is  often  of  great 
assistance. 

Hysterical  contraction  of  the  fingers  and  hands  is  some- 
times severe.  The  treatment  is  the  treatment  of  hys- 
teria with  such  local  treatment  as  may  be  necessary. 


DEFOEMITIES   OF   THE   PELVIC    GIRDLE   AND 
LOWER    EXTREMITY 

AFFECTIONS   OF   THE   PELVIS 

AFFECTIOlSrS    OF    THE    PeLVIC    BoNES 

The  bones  of  the  pelvis  sometimes  become  infected 
by  pns,  tubercle,  or  other  microbes,  without  the  involve- 
ment of  the  hip-joint  or  spine.  Such  infections  may  be 
puzzling  and  difficult  to  treat,  but  the  principles  of  treat- 
ment are  those  laid  down  in  the  general  part.  Secondary 
involvement  of  the  pelvis  is  common  in  hip  disease. 

Affections  of  the  Saceo-iliac  Joints 

Anatomy  and  Causation. — The  sacrum  is  connected  with 
the  ilium  on  either  side  by  well-developed  joints  covered 
by  smooth  cartilage,  permitting  a  rocking  motion  on  a 
horizontal  axis  passing  through  the  middle  (second  ver- 
tebra) of  the  sacrum.  These  joints  are  held  in  place  and 
protected  by  neighboring  muscles  and  by  very  strong 
ligaments,  which  are  less  developed  in  front  than  be- 
hind. All  the  large  movements  of  the  trunk  and  lower 
limbs  impose  strains  upon  and  cause  motion  in  the  iliac 
joints.^  The  motion  at  these  joints  is  increased  dur- 
ing pregnancy,  parturition,  and  menstruation,  and  may 
become  so  excessive  as  to  cause  much  pain  across  the 

^  The  term  "iliac"  joint  is  proposed  instead  of  the  awkward  and  inaccurate 
"sacro-iliac  synchondrosis." 

239 


240       DEFOEMITIES   OF   PELVIC    GIRDLE 

sacrum,  and  disability  in  standing  and  walking;  this 
looseness  and  disability  may  persist.  Congestion,  sore- 
ness, and  looseness  may  accompany  chronic  congestion 
of  the  female  pelvic  organs,  owing  to  the  close  relation 
of  the  blood  and  nerve  supply. 

It  is  important  to  realize  that  sacro-iliac  affections 
are  not  confined  to  the  pregnant  state  nor  to  women,  but 
that  these  structures  are  subject  to  the  same  injuries  and 
disorders  as  other  joints,  and  give  rise  to  definite  and 
characteristic  symptoms.  A  large  and  important  group 
of  sacro-iliac  affections  are  traumatic,  and  these  are 
more  common  in  men.  Falls,  blows,  twists,  or  heavy 
lifting  may  strain,  sprain,  or  displace  one  or  both  iliac 
joints,  or  the  injury  may  be  due  to  a  continued  strain, 
as  prolonged  recumbency  during  fevers,  after  fractures 
or  surgical  operations,  or  to  the  strain  of  a  heavy  pendu- 
lous abdomen,  or  of  affections  causing  limping  or  an 
unequal  distribution  of  stress,  such  as  scoliosis,  hip 
disease  or  ankylosis,  and  other  affections  of  the  lower 
extremity,  or  of  bad  postures  favored  by  certain  occu- 
pations. The  hypotonus  of  neurasthenia  may  result  in 
sacro-iliac  incompetence  and  hyperesthesia.  It  is  often 
difficult  here,  as  in  other  organs,  to  decide  how  much  of 
the  difficulty  is  purely  functional  and  how  much  is  due 
to  structural  change.  When  sacro-iliac  relaxation  is 
present,  it  exerts  an  unfavorable  effect  on  the  neuras- 
thenia, as  do  even  comparatively  slight  disabilities  in 
other  organs.  In  general  lack  of  vigor,  without  neuras- 
thenia, the  weakness  of  the  tissues,  particularly  if  com- 
bined with  faulty  dress  (high  heels)  or  faulty  postures 
(hollow  back,  over  straight  back,  weak  feet),  may  result 


SACRO-ILIAC   JOINTS  241 

in  sacro-iliac  strain.  Lastly,  the  iliac  joints  are  also  sub- 
ject to  the  usual  infections  and  diseases  of  the  large 
articulations.  Primary  tuberculous  infection  is  rare,  but 
may  occur ;  secondary  tuberculous  infection  is  more  fre- 
quent. Septic  or  gonococcic  infection  may  occur  as  a 
puerperal  complication  or  at  other  times,  and  typhoid 
and  other  specific  infections  are  known.  When  the  joint 
is  infected  there  may  be  a  boggy  swelling  in  its  vicinity, 
and  an  abscess  may  occur,  which  often  breaks  inside  the 
pelvis.    Osteoarthritis  of  the  iliac  joint,  usually  compli- 


FiG.  127. — Synostosis  of  the  Right  Sacro-iliac  Joint  from  Osteoar- 
thritis. The  one  at  the  left  shows  six  sacral  vertebrae.  (The  specimens 
are  from  Cornell  Medical  College.) 

eating  osteoarthritis  of  the  spine,  is  not  at  all  uncom- 
mon, and  strains  and  injuries  may  result  in  local  osteo- 
arthritis, as  in  other  joints.  The  osteophytes  may  cause 
a  pseudo-sciatica  or  leg  pain.  The  process  often  ends 
in  ankylosis  of  the  joint;  such  specimens  are  common 
in  the  museums  (Fig.  127). 


242       DEFORMITIES    OF   PELVIC    GIRDLE 

The  symptoms. are  tenderness  over  the  joint,  pain  near 
the  joint  or  across  the  sacrum  or  lower  back,  and  referred 
pain  due  to  pressure  on  the  important  nerves  pansing 


Fig.  128. — Strain  of  Left  Sacro-iliac  Joint  with  Deviation  of  Trunk 
TO  Right  from  a  Sneeze  Six  Weeks  Before.  Pelvic  strapping  with 
adhesive  plaster. 

in  front  of  the  joint,  namely  certain  cords  of  the  lumbar 
and  sacral  plexus.  The  pains  may  be  referred  down  the 
leg,  to  the  gluteal  region,  to  the  hip,  or  to  the  region  of 


SACEO-ILIAC   JOINTS  243 

the  iliac  fossa  and  groin.  Pain  or  discomfort  may  be 
felt  in  standing,  sitting,  and  lying,  and  is  aggravated 
when  the  patient  changes  from  one  posture  to  another. 
Pain  at  or  near  the  affected  joint  is  elicited  when  the 
patient  is  recumbent  by  flexing  either  thigh  with  the 
knee  straight;  the  amount  of  flexion  in  this  posture  is 
also  limited,  more  on  the  affected  side.  Movements  at 
the  hip  with  the  Imee  flexed  are  usually  free.  Forward 
stooping  and  lateral  trunk  movements — indeed,  any 
movements  putting  a  severe  strain  on  the  iliac  joints — 
may  be  limited  or  impossible.  The  weight  in  standing 
is  borne  on  the  well  leg,  and  lameness  is  often  present.' 
In  cases  of  long  standing  there  is  atrophy  of  the  leg  to 
palpation,  and  sometimes  to  measurement.  There  is  fre- 
quently a  marked  curvature  of  the  spine,  with  the  con- 
vexity toward  the  well  side  (Fig.  128). 

Diagnosis. -^Sacro-iliac  atfections  may  be  acute  or 
chronic,  mild  or  severe;  they  often  incapacitate  the  pa- 
tient from  work,  and  sometimes  render  him  helpless  for 
life.  The  milder  cases  may  be  obscure  and  lead  to  seri- 
ous errors  in  diagnosis,  but  may  usually  be  made  out 
after  careful  study.  The  acute  traumatic  cases  are  to 
be  distinguished  from  lumbago,  muscular  rheumatism, 
and  sciatica.  In  sciatica  the  pain  follows  the  sciatic  dis- 
tribution, and  there  is  tenderness  over  the  nerve  trunk; 
the  symptoms  are  often  relieved  by  recumbency,  which 
is  not  the  case  in  sacro-iliac  affections.  A  sciatica  may 
be  secondary  to  sacro-iliac  disease  or  displacement.  In 
lumbago  and  muscular  rheumatism  the  pain,  tenderness, 
and  stiffness  are  in  the  lumbar  region,  and  more  diffused. 
Crick-in-the-back  is  an  indefinite  term  which  may  be  ap- 


244       DEFORMITIES    OF    PELVIC    GIRDLE 

plied  to  lumbago  or  to  sacro-iliac  strain.  Sacro-iliac 
affections  may  be  mistaken  for  ovarian,  tubal,  or  uterine 
affections,  and  the  two  not  infrequently  coexist  and  exert 
an  unfavorable  reciprocal  influence;  the  same  may  be 
said  of  neurasthenia.  The  lower  abdominal  and  inguinal 
pains  sometimes  present  in  sacro-iliac  affections  have 
been  mistaken  for  gall-stone  colic  and  for  chronic  appen- 
dicitis. Chronic  cases  may  be  mistaken  for  disease  of 
the  hip  or  lumbar  spine,  but  in  hip  disease  motion  at 
the  hip  is  always  limited,  and  there  are  usually  malposi- 
tions of  the  thigh,  a  characteristic  gait,  and  often  short- 
ening of  the  limb.  In  disease  of  the  lumbar  spine  there 
is  stiffness  of  that  region,  and  often  a  projection,  but 
osteoarthritis  of  the  lumbar  spine  and  of  the  iliac  joints 
often  coexist. 

The  treatment  consists  in  pelvic  support  by  a  belt  or 
corset,  snugly  adjusted  above  the  trochanters.  Strap- 
ping the  pelvis  just  above  the  trochanters  by  several 
strips  of  two-inch  zinc-oxid  adhesive  plaster,  reaching 
beyond  the  anterior  spines,  will  often  give  speedy  and 
marked  relief,  which  is  of  considerable  diagnostic  value. 
A  wide  webbing  belt,  fastened  by  one  or  two  buckles 
in  front,  may  be  used;  to  prevent  slipping  upward  it 
may  be  attached  to  the  lower  end  of  a  long  corset, 
and  held  down  by  garters.  Often  a  long  plaster  jacket 
closely  applied  to  the  pelvis  will  be  required.  It  is  usu- 
ally possible  to  relieve  the  pain  and  enable  the  patient 
to  resume  work.  Occasionally  a  disability  which  has 
lasted  for  years  will  disappear  as  if  by  magic  under 
pelvic  support.  Chronic  uterine  or  ovariau  disease  and 
neurasthenia  should  be  treated  if  present.     Sacro-iliac 


DEFORMITIES   OF   LOWEB   EXTREMITY    245 

displacement  may  require  reduction  by  special  postures 
or  manipulations,  with  or  without  anesthesia,  before  sup- 
port is  applied, 

DEFORMITIES  OF  THE  LOWER  EXTREMITY 

General  Remarks 

The  structure  of  the  lower  extremity  is  more  massive 
than  that  of  the  upper,  and  is  adapted  to  support  and 
propulsion;  traces  only  of  prehension  remain.  In  the 
absence  of  active  disease  the  disabilities  of  the  lower 
limb — malposition,  weakness,  stiffness,  and  shortening — 
are  of  importance  in  the  order  given.  A  stiff  hip  in  good 
posture,  even  if  combined  with  some  shortening,  makes 
an  exceedingly  serviceable  leg;  the  same  may  be  said  of 
the  knee  and  ankle.  A  much  flexed  thigh  or  knee  or 
extended  ankle  makes  a  very  poor  leg,  even  with  motion 
and  no  actual  shortening.  The  principal  orthopedic  aim 
in  the  management  of  affections  of  the  lower  extremity 
should  be  to  prevent  or  correct  deformity  at  the  major 
joints,  and  thus  retain  or  restore  the  supporting  func- 
tion of  the  legs.  No  matter  how  helpless  a  leg  may  be, 
it  may  always  be  straightened  and  braced  or  stiffened 
so  that  very  fair  locomotion  is  possible,  provided  the 
least  affected  leg  is  strong  enough  to  stand  on.  In  some 
cases  where  both  legs  are  used  as  props,  locomotion  with 
or  without  crutches  is  still  possible.  If  the  fact  be  borne 
in  mind  that  the  fundamental  function  of  the  human  leg 
is  that  of  support,  very  few  parts  will  be  found  to  be 
indispensable.  This  is  still  further  emphasized  by  the 
assumption  of  the  function  of  the  damaged  part  by  other 


246     DEFORMITIES   OF   LOWER   EXTREMITY 

structures.  If  one  hip  is  stiff,  the  motion  which  properly 
belongs  to  it  is  so  distributed  between  the  lumbar  spine, 
iliac  joints,  well  hip,  and  knees,  that  if  the  posture  of  the 
thigh  is  good  the  loss  is  hardly  felt  in  walking.  In  sit- 
ting and  stooping,  however,  the  embarrassment  is  con- 
siderable, as  the  necessary  wide  range  of  hip  motion 
cannot  be  fully  compensated.  In  total  paralysis  of  the 
quadriceps  good  locomotion  without  artificial  support  is 
often  possible,  either  by  mechanically  locking  the  knee 
back  like  a  carpenter's  rule,  or  by  extension  of  the  femur 
on  the  pelvis  through  contraction  of  the  glutei,  which, 
when  the  foot  is  on  the  ground,  necessarily  extends  the 
knee ;  the  danger  in  these  methods  of  locomotion  is  that 
the  knee  may  become  hyperextended.  In  amputation  the 
supporting  power  of  the  stump  and  of  the  rest  of  the 
limb  is  to  be  largely  considered.  Many  amputations, 
especially  of  the  foot,  leave  a  stump  affording  poor  sup- 
port, and  are  therefore  unserviceable.  The  best  posture 
for  a  stiff  hip  is  with  a  flexion  and  abduction  of  ten  to 
fifteen  degrees;  for  the  knee,  also,  slight  flexion  is  de- 
sirable, but  on  account  of  the  danger  of  increase  of  flexion 
the  knee  is  usually  put  up  straight  after  an  excision ;  the 
foot  may  drop  slightly  below  a  right  angle  in  order  to 
allow  for  the  heel  of  the  boot,  but  abduction  and  ever- 
sion  should  be  avoided. 

Defokmities  of  the  Hip 

Congenital  dislocation  of  the  femoral  head  is  the  common- 
est congenital  dislocation;  it  is  six  times  more  frequent 
in  girls  than  in  boys,  and  is  oftener  single  than  bilateral. 
The  subjects  of  this  deformity  are,  in  the  large  majority 


THE    HIP  247 

of  cases,  otherwise  perfectly  formed  and  without  inher- 
ited tendency,  though  exceptions  to  both  of  these  state- 
ments occur. 

Etiology. — In  a  few  cases  there  is  a  general  loose- 
ness of  the  ligamentous  structures  of  the  body.  Eare 
instances  are  due  to  trauma  at  birth;  these  are,  strictly 
speaking,  not  congenital  but  acquired  dislocations.  The 
large  majority  of  the  cases  seem  to  be  due  to  a  forced 
posture  of  the  lower  limbs  in  utero  due  to  scanty  amni- 
otic fluid  or  other  causes.  In  posterior  dislocations  the 
thighs  are  kept  flexed  and  adducted,  and  the  heads  are 
forced  against^he  posterior  superior  part  of  the  capsule, 
which  gradually  yields  and  allows  the  head  to  slip  out 
of  the  socket;  in  many  cases,  however,  the  dislocation 
is  anterior  or  superior.  In  the  female  the  acetabulum 
is  placed  farther  to  the  side,  thus  favoring  luxation. 

Pathological  Anatomy. — With  the  femoral  head  dis- 
placed, the  acetabulum  is  not  fully  developed,  but  re- 
mains shallow,  narrow,  and  of  irregular  shape ;  the  upper 
rim  is  especially  defective.  The  changes  in  the  joint 
structure  are  slight  at  birth,  but  increase  with  age,  and 
more  rapidly  after  the  child  begins  to  walk.  Some  au- 
thorities state  that  the  dislocation  is  at  first  upward,  and 
that  it  changes  by  degrees  into  the  posterior  displace- 
ment. There  is  always  an  acetabulum  in  approximately 
its  normal  location  (Fig.  129).  Sherman,  who  advocated 
arthrotomy  and  incision  of  the  capsular  stricture  as  a 
routine  measure,  states  that  the  acetabulum  is  nearly 
always  sufficiently  capacious  to  retain  the  replaced  head 
without  the  necessity  of  enlargement.  The  head  is  usu- 
ally larger  than  the  acetabulum,  and  more  or  less  flat- 


248     DEFORMITIES    OF   LOWER   EXTREMITY 

tened  or  deformed ;  the  neck  is  usually  anteverted  so  as 
to  evert  the  limb.  The  ligamentum  teres  may  be  length- 
ened, enlarged,  or  absent.    The  capsule  in  time  becomes 


.■ 

■ 

■ 

.^^mjk 

1 

■ 

wm 

gU^^ 

IB: 

BH 

Fig.  129. — Congenital  Posterior  Superior  Dislocation  of  the  Right 
Hip  in  a  Girl  of  Four.  This  was  easily  reduced  under  ether;  the  head 
remained  in  the  socket  after  three  months'  retention  in  plaster. 

elongated  and  thickened;  if  there  is  much  displacement 
the  upper  part  is  wrapped  about  the  head  like  a  hood, 
while  the  lower  part  is  drawn  over  the  acetabulum,  form- 
ing a  pocket  or  hymen;  the  part  between  is  constricted 
(hour-glass  contraction),  and  may  be  adherent  to  the 
parts  to  which  it  is  applied.  The  pelvis  is  atrophied  on 
the  affected  side  in  old  cases. 

The  pelvi-trochanteric  muscles,  whose  direction  crosses 
that  of  the  femur,  are  lengthened  and  atrophied.     The 


THE    HIP 


249 


adductors  and  pelvi-crural  muscles  running  parallel  to 
the  femur  are  shortened.  Even  in  the  older  cases  there 
is  seldom  much  shortening  of  the  limb,  except  that  due 
to  the  displacement.  In  some  of  the  very  old  cases  the 
head  may  rub  through  the 
capsule,  and  form  a  near- 
throsis. 

Symptoms. — The  first 
symptom  to  attract  at- 
tention is  usually  a  pain- 
less lameness  when  the 
child  begins  to  walk.  This 
is  usually  about  eighteen 
months  of  age,  sometimes 
later.  If  one-sided,  the 
instability  and  displace- 
ment (shortening)  of  the 
leg  cause  an  unsteadiness 
or  limp  on  the  affected 
side.  The  shortening  and 
upward  displacement  of 
the  trochanter  are  slight 
at  first,  often  not  over  a 
quarter  to  half  an  inch, 
but  increase  with  the 
stretching  of  the  capsule, 
until  in  children  of  eight 
or  ten  it  may  amount  to 
two  inches  or  more  (Fig. 
130).  The  trochanter  is 
prominent  on  the  luxated 

18 


Fig.  130.  —  Congenital  Posterior 
Dislocation  of  the  Left  Hip  in 
A  Girl  of  Eight.  Left  trochan- 
ter 1^  inches  high,  and  the  left 
leg  is  short  by  the  same  amount. 
Notice  compensatory  spinal  bend- 
ing without  rotation. 


250     DEFORMITIES    OF    LOWER    EXTREMITY 

side,  and  rises  above  Nelaton's  line  by  the  amount  of 
the  shortening.  If  with  the  child  lying  on  its  back  the 
leg  is  grasped  above  the  knee  and  the  thigh  flexed,  ad- 
ducted,  and  rotated,  the  head  may  be  felt  moving  on 
the  dorsum  of  the  ilium  under  the  fingers  of  the  free 
hand.  In  the  extended  posture  the  trochanter  and  fem- 
oral head  may  be  forced  up  and  down  on  the  pelvis 
(pumping  or  telescoping). 

The  limp  is  caused  not  only  by  this  telescoping,  when 
the  weight  of  the  body  is  put  upon  the  dislocated  hip, 
but  also,  according  to  Trendelenburg,  by  the  sagging  of 
the  pelvis  toward  the  sound  side,  owing  to  the  inability 
of  the  gluteal  muscles  of  the  affected  side  to  preserve  its 
horizontality.  There  is  increased  lordosis  in  standing 
owing  to  increased  forward  inclination  of  the  pelvis,  and 
also  a  lateral  bending  of  the  spine  toward  the  short  side, 
which  seldom  becomes  a  fixed  scoliosis.  Abduction  and 
sometimes  other  movements  are  limited,  but  there  is  no 
spasm,  unless,  as  occasionally  happens,  the  luxated  hip 
should  become  infected  or  irritated.  In  the  older  cases 
the  thigh  may  become  flexed  and  adducted.  The  above 
description  applies  to  the  majority  of  the  cases,  which, 
when  brought  for  examination,  are  luxated  upward  and 
backward  on  the  dorsum  of  the  ilium. 

Cases  of  persistent  anterior,  and  of  supracotyloid, 
dislocation  are  not  uncommon.  In  the  former  the  head 
is  felt  below  or  to  the  outer  side  of  the  anterior  superior 
spine  of  the  ilium.  This  position  is  much  more  stable 
than  in  the  posterior  dislocation;  there  is  less  telescop- 
ing, less  lameness  and  disability,  and  less  tendency  to 
increase  of  shortening,  and  as  the  weight  is  carried  over 


THE    HIP 


251 


or  in  front  of  the  acetabulum  there  is  no  lordosis.  In 
an  anomalous  case  of  anterior  displacement  reduced  by 
the  writer,  the  child  was  born  with  the  foot  behind  the 


Fig.  131. — ^The  Child  to  the  Left  is  a  Girl  Three  Years  Old;  She  has  an 
Anterior  Dislocation  of  the  Right  Hip.  The  Boy  to  the  Right, 
Two  Years  Old,  has  a  Bilateral  Upward  Dislocation. 

opposite  buttock,  and  there  was  paralysis  with  perma- 
nent flexion  of  the  knee,  pes  equinus,  and  interference 
with  the  growth  of  the  leg,  probably  from  a  birth  injury 
to  the  sacral  plexus.   In  certain  of  the  supracotyloid  cases 


252     DEFOEMITIES    OF    LOWER    EXTREMITY 


the  head  easily  passes  to  the  dorsum  when  the  thigh  is 
flexed  (Fig.  131). 

In  bilateral  dislocation  of  the  hip  the  symptoms  are 
present  on  both  sides.  If  the  displacement  is  equal  the 
legs  will  be  of  equal  length,  and  the  shortening  is  meas- 
ured by  the  displacement 
of  the  trochanters  above 
Nelaton's  line.  Not  in- 
frequently one  hip  is 
more  displaced  than  the 
other,  and  there  is  then 
a  difference  in  the  length 
of  the  legs.  It  is  also 
to  be  remarked  that  the 
skiagram  may  reveal  a 
narrow  rim  or  a  slight 
subluxation  on  the  side 
opposite  to  the  luxated 
hip  in  apparently  unilat- 
eral cases.  Such  hips 
may  slip  out  during  the 
treatment  of  the  luxated 
side.  Viewed  from  in 
front  or  behind,  the  legs 
seem  short  and  the  hips 
abnormally  broad.  Lor- 
dosis is  more  pronounced  than  in  unilateral  dislocation, 
and  the  disability  is  greater.  Abduction  is  more  re- 
stricted. In  a  case  of  bilateral  supracotyloid  disloca- 
tion in  a  girl  of  twelve,  the  legs  were  crossed  above  the 
knees — scissors  deformity — and  progression  took  place 


Fig.  132. — Congenital  Upward  Dis- 
location OF  Both  Hips;  Congeni- 
tal Right  Pes  Varus,  Left  Pes 
Valgus;  Girl  of  Twelve. 


THE    HIP  253 

in  this  posture  (Fig.  132).  The  ordinary  gait  of  the 
bilateral  cases  is  waddling,  and  very  characteristic. 

These  children  are  usually  well  and  lively,  and  are 
always  able  to  walk;  they  seldom  suffer  much  discom- 
fort; as  they  grow  older,  however,  and  become  heavier, 
the  strain  on  the  capsular  ligaments  becomes  greater, 
abduction  becomes  more  restricted,  and  disability  in- 
creases. About  puberty,  or  soon  after,  more  or  less  pain 
about  the  hip  and  thigh  is  complained  of,  and  the  dis- 
tance which  the  patient  can  walk  is  progressively  cur- 
tailed until,  in  adult  life,  short  distances  may  be  accom- 
plished with  difficulty. 

The  DIAGNOSIS  is  seldom  made  until  the  child  begins 
to  walk,  as  pain  is  absent,  and  the  slight  displacement  is 
usually  unnoticed.  In  sj)ite  of  the  persistent  and  char- 
acteristic lameness  many  children  are  not  brought  to  the 
physician's  attention  until  they  are  quite  large.  From 
the  symptoms  mentioned  the  diagnosis  is  usually  not 
difficult;  obscure  cases  are  cleared  up  by  a  good  skia- 
gram, which  should  always  be  taken  as  a  matter  of  rec- 
ord. The  combination  of  high,  prominent  trochanter, 
loose  joint,  and  palpable  head  is  found  only  in  luxation ; 
the  history  and  other  features  will  determine  whether 
the  luxation  be  paralytic,  pathological,  traumatic,  or  con- 
genital. One  should  bear  in  mind  the  somewhat  different 
symptoms  of  an  anterior  or  superior  displacement.  In 
severe  paralysis  of  the  hip  muscles  after  poliomyelitis, 
the  head  occasionally  slips  out.  In  such  cases  there  is 
extreme  looseness  and  wasting  of  all  the  tissues,  and  the 
hip  can  be  easily  slipped  in  and  out  of  the  socket  with 
little  force  and  no  pain.     In  suppurative  coxitis  of  in- 


254     DEFORMITIES    OF    LOWER    EXTREMITY 

fants  the  head  is  often  entirely  destroyed,  and  the  gait, 
looseness,  and  position  of  the  trochanters  indicate  femo- 
ral displacement.  The  head  of  the  femur  cannot  be  felt, 
as  it  is  lacking,  and  there  is  often  the  scar  of  an  old 
sinus.  In  coxa  vara  the  head  is  not  palpable  and  the 
joint  is  not  loose.  In  rachitic  curvature  of  the  upper 
end  of  the  femur  the  gait  may  be  waddling  and  the  gen- 
eral appearance  suggestive  of  congenital  luxation,  but 
the  femora  are  bowed,  marked  signs  of  rickets  are  pres- 
ent, and  the  heads  are  in  their  sockets. 

The  PROGNOSIS  of  untreated  cases  as  to  improvement 
is  bad;  the  tendency  is  for  the  displacement  and  disabil- 
ity to  markedly  increase  as  the  patient  gets  older  and 
heavier.  Under  proper  treatment  substantial  improve- 
ment is  effected  in  the  large  majority  of  cases,  while  in 
many  the  result  is  practically  perfect.  The  bilateral 
cases  are  much  more  difficult,  and  in  them  the  results 
are  less  perfect  than  in  the  unilateral. 

Treatment  was  palliative  until  the  labors  of  Paci, 
Schede,  Hoffa,  and  Lorenz  made  the  replacement  of  the 
dislocated  femoral  head  a  standard  surgical  procedure. 
Paci  accomplished  by  leverage  manipulations  a  trans- 
position of  the  femoral  head,  giving  improved  position 
and  function.  Schede,  after  preliminary  traction,  some- 
times obtained  a  true  reduction  by  forcible  mechanical 
traction  under  anesthesia.  Hoffa  enlarged  the  acetabu- 
lum by  means  of  a  large  excavator  through  an  open 
incision,  and  replaced  the  head.  This  operation  was 
adopted  with  slight  modifications  by  Lorenz,  who  was 
afterwards  led  to  perfect  bloodless  reposition  on  account 
of  some  fatalities,  and  the  stiffness  often  following  the 


THE    HIP  255 

open  operation.  Bloodless  replacement,  variously  modi- 
fied, is  now  the  standard  treatment  for  one-sided  cases 
under  ten  and  bilateral  cases  under  eight.  The  older 
the  case  the  more  difficult  the  manipulation  and  the  more 
uncertain  the  result,  though  the  difficulty  depends  more 
upon  rigidity  of  the  tissues  and  the  amount  of  the  dis- 
placement than  upon  the  age.  Some  of  the  older  dislo- 
cations occasionally  slip  into  place  with  great  ease,  as  in 
the  case  of  a  girl  of  eight  recently  reduced  by  the  writer. 
Treatment  may  be  begun  as  soon  as  the  diagnosis  is  made, 
but  it  is  doubtful  if  there  is  any  real  advantage  in  re- 
placing the  dislocation  before  the  age  of  two  or  three 
years,  as  the  splint  is  soiled  by  the  baby  and  the  femoral 
head  is  not  readily  retained  in  position  by  the  delicate 
tissues.  When  there  is  much  rigidity  and  displacement 
preliminary  traction  in  bed,  with  a  weight  of  ten  to 
twenty  pounds  for  two  or  three  weeks,  makes  the  repo- 
sition much  less  difficult,  and  is  frequently  indispensable. 
In  very  difficult  cases  it  is  recommended  to  divide  the 
adductor  magnus  at  its  insertion  (Bradford)  and  the 
hamstrings,  either  before  or  at  the  operation,  though 
this  is  seldom  necessary. 

The  technic  employed  by  Lorenz  during  his  American 
trip  in  1903-4  was  as  follows:  The  patient  being  anes- 
thetized and  placed  in  the  dorsal  decubitus  on  a  flat  pad, 
the  pelvis  was  seized  and  steadied  by  an  assistant  while 
the  operator  flexed  the  affected  thigh  to  ninety  degrees 
and  made  continuous  forcible  abduction.  This  caused  the 
adductor  tendons  to  stand  out  like  rigid  cords ;  these  were 
then  sharply  struck  by  the  ulnar  border  of  the  hand  or 
by  the  fist,  in  order  to  tear  the  retracted  muscles.    After 


256      DEFOEMITIES    OF    LOWER    EXTREMITY 

abduction  had  been  carried  beyond  the  frontal  plane,  an 
effort  was  made  to  pry  the  head  of  the  femur  into  the 
socket  by  leverage  over  the  fist  or  over  the  wedge.  This 
was  often  successful  and  reduction  was  announced  by  an 
audible  and  palpable  shock.  If  the  displacement  was  not 
reduced  by  abduction  and  leverage,  and  especially  if  the 
upward  displacement  was  great,  a  sheet  was  folded  diag- 
onally, the  ends  tied  together,  and  passed  under  the  oppo- 
site groin  and  over  an  upper  corner  of  the  table.  With 
an  assistant  still  steadying  the  pelvis,  the  displaced  leg 
was  grasped  and  jDulled  downward  with  some  abduction 
and  rotation;  reduction  sometimes  occurred  during  this 
maneuver  (Schede's  method),  but  usually  after  the  tro- 
chanter had  been  sufficiently  brought  down,  the  reduc- 
tion followed  over  the  thumb,  fist,  or  wedge  in  forced 
abduction.  The  signs  of  reduction  are  a  sudden  jar,  an 
audible  click,  the  diminished  prominence  of  the  trochan- 
ter, the  disappearance  of  the  hollow  in  the  groin,  and 
its  replacement  by  a  hard  body,  the  anterior  portion  of 
the  head  of  the  femur.  After  reduction  the  thigh  tends 
to  remain  in  abduction  and  flexion,  and  the  hamstrings 
are  retracted  and  prevent  full  extension  at  the  knee  un- 
less forcibly  stretched.  When  the  flexion  or  the  abduc- 
tion is  diminished  the  head  slips  out  with  a  jar  and 
click,  but  is  easily  replaced.  By  dislocating  the  head  over 
the  posterior  superior  and  inferior  borders  of  the  acet- 
abulum, these  may  be  palpated  and  their  development 
estimated.  The  stability  of  the  reposition  may  be  esti- 
mated from  the  development  of  the  superior  and  poste- 
rior portions  of  the  rim,  and  from  the  amount  by  which 
the  flexion  may  be  lessened  without  causing  dislocation. 


THE    HIP  257 

Once  the  head  of  the  femur  is  in  its  socket,  this  is  en- 
larged and  the  contracted  anterior  portion  of  the  cap- 
sule stretched  by  repeated  movements  of  rotation  and 
circumduction  of  the  flexed  and  abducted  thigh;  abduc- 
tion is  also  increased  to  well  beyond  the  frontal  plane. 
Also  the  hamstrings  are  stretched  by  extending  the 
knee,  the  child  is  placed  on  the  well  side,  and  the  knee 
is  flexed  so  that  the  foot  lies  in  front  of  the  shoulder, 
and  hyperextended  to  the  limit  of  motion.  If  both  hips 
are  dislocated  the  abductors  are  stretched  simultaneous- 
ly, one  side  is  completely  reduced  in  the  manner  above 
described  and  the  other  side  is  reduced  afterwards  by 
similar  manipulations  at  the  same  sitting.  After  reduc- 
tion the  thigh  is  retained  in  right-angled  flexion  and 
hyperabduction  by  a  short,  thick,  narrow  spica  encircling 
the  pelvis  and  reaching  to  the  knee,  cut  out  in  front  and 
behind  to  prevent  soiling.  When  the  displacement  is 
bilateral  the  spica  includes  both  thighs  to  the  knee,  and 
the  patient  is  placed  in  the  "  frog  position."  Lorenz  rec- 
ommended that  the  patient  should  be  made  to  walk  in 
a  few  days,  with  the  idea  that  such  efforts  would  force 
the  replaced  head  deeper  into  the  acetabulum,  stimulate 
its  development,  and  thus  increase  the  stability  of  the 
reposition.  He  advised  that  the  first  spica  remain  six 
months,  that  the  flexion  and  abduction  should  then  be 
reduced,  and  a  second  spica  applied  in  this  secondary 
position,  to  be  worn  three  months,  followed  by  more 
spicas  if  necessary.  After  the  removal  of  the  last  spica 
much  attention  was  given  to  massage  and  to  movements 
of  flexion  and  extension  in  the  plane  of  abduction, 
movements  of  hyperextension,  and  other  movements  to 


258     DEFOEMITIES    OF    LOWER    EXTREMITY 

strengthen  the  muscles  previously  lengthened  and  which 
oppose  redislocation.  The  results  of  this  treatment  were 
excellent  with  anatomical  replacement  in  about  one  quar- 
ter, anterior  transposition  with  improved  function  in 
about  one  half,  and  poor  in  the  remainder.  The  force 
used  in  the  resistant  cases  was  very  great;  serious  acci- 
dents followed  in  several  instances,  and  minor  complica- 
tions, such  as  anterior  crural  palsy,  iti  many.  Further 
experience  has  led  the  writer  to  modify  this  technic  in 
the  following  particulars.  In  all  difficult  cases  prelim- 
inary traction  to  the  point  of  toleration  was  used  for 
several  weeks.  Pounding  the  adductors  is  omitted;  they 
yield  to  continuous  stretching.  Movements  of  extreme 
flexion  and  extension  are  also  omitted,  and  only  mod- 
erate force  is  employed.  Rather  than  injure  the  patient, 
it  is  better  to  be  satisfied  with  getting  the  head  of  the 
femur  near  the  acetabulum  and  j)ut  the  thigh  up  on 
flexion  and  abduction,  as  though  reduced,  when  at  a  sec- 
ond attempt  later  on  it  may  slip  in  easily.  Nevertheless, 
a  moderate  amount  of  force  will  usually  prove  success- 
ful at  the  first  attempt  in  cases  suited  to  the  bloodless 
method.  Ridlon  reduces  the  displacement  by  flexing  the 
thigh  until  it  is  in  contact  with  the  abdomen,  grasping 
the  displaced  head  between  the  thumb  and  fingers  of  the 
free  hand,  and  guiding  it  into  the  socket  during  forced 
abduction  and  outward  rotation  of  the  thigh. 

Besides  the  methods  of  replacement  of  Lorenz  and 
Schede  already  mentioned,  there  are  others  that  may  be 
tried,  especially  that  of  Schanz,  which  consists  in  flexing 
the  adducted  thigh  on  the  abdomen  and  pulling  sharply 
upward  toward  the  opposite  shoulder,  the  pelvis  being 


THE    HIP  259 

held  by  an  assistant.  The  methods  of  Schede  and  Schanz 
depend  upon  traction  rather  than  leverage  for  the  re- 
duction of  the  displacement ;  Calot  of  Berck  has  worked 
out  a  manual  traction  and  propulsion  method,  and  a  plan 
of  management  which  differs  widely  from  the  Lorenzian, 
and  has  given  him  and  others,  including  the  writer,  most 
satisfactory  results.  He  recommends  three  maneuvers 
for  reduction,  which  are  to  be  patiently  tried  in  succes- 
sion if  necessary. 

(1)  While  an  assistant  fixes  the  pelvis,  flex  the  thigh 
and  knee  to  a  right  angle ;  pull  up  on  the  thigh  grasped 
near  the  knee  with  one  hand,  and  at  the  same  time  push 
up  behind  the  trochanter  with  the  thumb  of  the  other. 
In  more  difficult  cases  an  assistant  pulls  up  the  thigh 
with  both  hands  while  the  operator  presses  upon  the 
trochanter  with  both  thumbs.  Four  thumbs  even  may 
press  upon  the  trochanter.  While  the  leg  is  pulled  it 
may  be  slightly  rotated  or  circumducted.  This  maneu- 
ver succeeds  within  ten  to  fifteen  minutes  in  most  cases. 

(2)  The  second  maneuver  is  like  the  first,  but  a  slow 
gradual  abduction  is  added,  the  trochanter  being  pushed 
into  place  by  the  thumbs  as  before.  This  combines  trac- 
tion, propulsion,  and  leverage. 

(3)  In  the  third  movement  the  patient  is  placed  on 
the  well  side,  and  the  flexed  thigh  is  placed  in  extreme 
adduction,  and  the  trochanter  pressed  and  pulled  into 
place  as  before. 

To  these  may  be  added  (4)  the  similar  maneuver  of 
Gwilym  Davis,  who  places  the  child  on  the  face,  with  the 
pelvis  resting  on  a  sand  bag  and  the  affected  leg  hanging 
down  beside  the  table,  and  pushes  down  upon  the  tro- 


260     DEFORMITIES    OF    LOWER    EXTREMITY 

chanter  with  the  closed  hands,  the  operator's  weight  as- 
sisting. An  assistant  gradually  abducts  the  thigh;  aid- 
ing the  forward  movement  by  traction  improves  the 
method.  Reduction  by  these  methods  is  less  dramatic 
than  by  the  method  of  leverage ;  there  is  less  shock  and 
click,  and  sometimes  none  at  all.  When  reduction  is 
effected  the  trochanter  sinks  or  crunches  away  from  the 
pressing  thumbs  into  the  depths  like  the  yielding  of  a 
piano  key  to  the  push  of  the  finger  (Calot).  Once  re- 
duced, the  signs  are  the  same  as  after  reduction  by  the 
leverage  method.  After  reduction  by  one  of  these  meth- 
ods the  adductors  are  stretched  and  the  thigh  is  placed 


Fig.  133. — Congenital  Dislocation  of  Hips;  Manual  Replacement  and 
Plaster  According  to  Calot  at  Post-Graduate  Hospital.  Photo- 
graph taken  two  days  after  the  operation ;  notice  ecchymosis  in  groins. 

at  seventy  degrees  flexion  and  seventy  degrees  abduction, 
as  m  this  position  much  more  of  the  head  is  in  contact 
with  the  acetabulum  than  in  extreme  flexion  and  abduc- 
tion, and  the  risk  of  anterior  luxation  is  less  (Fig.  133). 


THE   HIP  261 

Calot  recommends  a  long  spica  to  include  the  foot,  no 
walking,  to  change  the  position  under  anesthesia  to  mod- 
erate abduction,  no  flexion,  and  inversion  after  three  and 


Fig.    134. — Left  Congenital  Hip   Dislocation;   Last  Posture;  Abduc- 
tion WITH  Inversion. 

a  half  months,  and  to  apply  another  long  spica  (Fig. 
134).  This  is  left  on  two  months,  when,  if  the  reduction 
is  stable,  it  may  be  removed  and  the  limb  allowed  to 
come  back  into  position  as  the  patient  lies  in  bed.  Since 
using  this  technic  the  writer  has  had  markedly  better 
results  and  no  accidents. 


262      DEFOEMITIES    OF    LOWER    EXTREMITY 

Wlien  the  deformity  is  too  rigid  to  be  safely  reduced 
by  manipulation,  the  open  operation,  as  perfected  by 
Hoffa  and  Lorenz,  may  be  used.  This  consists  in  open- 
ing the  joint  through  an  incision  in  front  of  the  great 
trochanter  (Hoifa)  or  at  the  outer  border  of  the  tensor 
fasciae  latae,  deepening  the  acetabulum  by  a  large  exca- 
vator and  placing  the  femoral  head  in  the  deepened 
socket.  This  operation  is  often  severe,  and  sometimes 
results  in  stiffness,  but  may  give  very  satisfactory 
results  in  difficult  cases.  Sherman,  of  San  Francis- 
co, advocates  opening  the  joint  at  any  age,  dividing 
the  capsular  stricture,  and  replacing  the  head  with- 
out deepening  the  acetabulum ;  he  reports  excellent 
results. 

In  anterior  dislocation,  if  the  joint  is  firm  and  loco- 
motion is  good,  no  treatment  is  necessary;  if  function  is 
poor,  the  thigh  is  flexed  and  adducted  and  the  head  pushed 
down  and  back.  The  leg  is  put  up  in  semiflexion,  mod- 
erate abduction,  and  inversion. 

In  the  case  of  bilateral  upward  dislocation  with  ex- 
treme adduction,  and  cross-legged  progression  in  a  girl 
of  twelve,  the  deformity  was  overcome  by  an  osteotomy 
below  the  trochanter  minor  on  each  side,  and  the  result 
was  excellent. 

In  certain  old,  irreducible  or  relapsing  cases  Hoifa 
advises  excision  of  the  head,  denudation  of  a  spot  above 
the  acetabulum,  against  which  the  sawn  neck  is  to  be 
placed  with  the  leg  abducted.  This  often  gives  good 
stability  and  freedom  by  the  formation  of  fibrous  adhe- 
sions or  of  a  pseudo-arthrosis.  Where  the  head  can  be 
drawn  down  to  the  level  of  the  acetabulum,  Albee's  shelf 


THE    HIP  263 

operation  (see  osteoarthritis  of  the  hip,  p.  299)  would 
seem  to  be  indicated. 

Coxa  Vara. — -The  axis  of  the  neck  of  the  femur  should, 
in  the  adult,  cut  that  of  the  shaft  at  about  one  hundred 
and  thirty  degrees ;  when  this  angle  is  markedly  smaller, 
the  trochanter  is  raised,  the  leg  is  shortened,  and  abduc- 
tion of  the  thigh  is  diminished.  This  condition  is  known 
as  (cervical)  coxa  vara,  and  may  be  congenital  or  due 
to  trauma,  to  rickets,  to  overweighting,  or  to  other 
causes  (Figs.  135  and  136).  In  another  set  of  cases,  usu- 
ally flabby  adolescents  of  rapid  growth,  the  deformity 
is  due  to  a  yielding  at  the  epiphyseal  line;  the  head  of 
the  femur  seems  to  slide  down  and  back  on  the  neck, 
while  the  latter  keeps  its  proper  direction  (epiphyseal 
coxa  vara)  (Fig.  137).  The  genesis  of  the  deformity  is 
similar  to  that  of  the  flat-foot  and  knock-knee  of  adoles- 
cence, with  which  it  is  often  associated.  As  in  the 
other  static  deformities  of  adolescence,  it  is  not  known 
whether  the  softening  is  specific  or  the  exaggeration  of 
a  normal  condition.  The  onset  is  usually  slow  and 
painless,  but  the  deformity  may  appear  suddenly  after 
a  slight  fall  or  moderate  injury.  Pain  may  appear 
fairly  early,  and  may  increase  in  intensity,  with  limp- 
ing and  restriction  of  hip  motion,  especially  in  abduc- 
tion and  inversion,  but  often  also  in  flexion.  Hip  mo- 
tions may  be  painful  if  pushed  to  the  limit,  and  there 
may  be  slight  spasm  during  the  active  stages  of  the 
process.  The  trochanter  is  prominent.  In  the  epiphy- 
seal cases  elevation  of  the  trochanter  and  shortening  of 
the  leg  may  be  slight  or  absent.  The  head  is  usually 
carried  backward  (convexity  of  neck  forward)  as  well 


264      DEFORMITIES    OF    LOWER   EXTREMITY 

as  downward,  so  that  the  feet  are  everted  and  the 
plane  of  flexion  is  deflected  outward.  If  the  deformity 
is  severe  the  thigh  becomes  adducted,  and  the  apparent 


Fig.  135. — Cervical  Coxa  Vara  in  a  Girl  of  Eight;  Lameness  of  One 
Year's  Duration.     (Hospital  for  the  Ruptured  and  Crippled.) 


THE    HIP 


265 


shortening  is  greater  than  the  reaL     Later  the  shape 
of  the  head  may  be  changed.     The  condition  may  exist 


Fig.  136. — Same  Case  Two  Months  after  Removal  of  Wedge  Below 
Trochanter  by  Whitman.     (Hospital  for  the  Ruptured  and  Crippled.) 
19 


266     DEFORMITIES    OF    LOWER    EXTREMITY 

on  both  sides,  when  lordosis  and  a  waddling  gait  are 
observed. 

Coxa  vara  may  be  due  to  an  injury  of  the  neck  at  any 
age.    Fracture  of  the  neck  of  the  femur  in  young  children, 


Fig.  137. — Epiphyseal  Coxa  Vara  (Bilateral)  in  a  Boy  of  Fourteen; 
THE  Angle  of  the  Neck  is  Unchanged. 


as  shown  by  Whitman,  is  by  no  means  rare,  and  usually 
gives  rise  to  a  traumatic  coxa  vara.  In  flabby  adolescents 
of  the  coxa  vara  type  slight  falls  may  produce  a  fracture 


THE    HIP  267 

or  acute  bending  of  the  neck.  In  adults,  also,  the  union 
of  a  fractured  femoral  neck  usually  leaves  a  permanent 
coxa  vara.  This  deformity  should  be  prevented  by  using 
Whitman's  abduction  treatment.     (See  page  302.) 

The  diagnosis  from  congenital  dislocation  is  not  dif- 
ficult; in  coxa  vara  the  head  is  in  the  socket,  and  there 
is  no  pumping.  In  certain  cases,  accompanied  by  much 
pain  and  stiffness,  it  may  be  difficult  to  exclude  coxitis 
without  a  skiagram,  which  should  always  be  taken;  the 
history  is  also  important. 

In  unilateral  cases  of  moderate  degree,  especially 
where  a  fair  amount  of  abduction  is  present,  the  patient 
should  be  put  on  crutches,  with  a  long  traction  hip  splint 
and  a  high  shoe  on  the  well  foot  to  relieve  the  hip  of 
weight  bearing,  and  attention  should  be  paid  to  the  gen- 
eral nutrition ;  the  bilateral  cases  should  be  kept  off  the 
feet  entirely.  This  treatment  proves  successful  in  many 
of  the  early  cases. 

When  the  deformity  has  developed  rapidly  and  the 
thigh  is  permanently  adducted,  forcible  abduction  and 
retention  in  plaster  may  correct  the  deformity  if  the  case 
is  seen  early.  In  cases  of  serious,  permanent  deformity, 
where  the  bone  is  hard,  an  osteotomy  should  be  done 
below  the  greater  trochanter,  and  the  leg  should  be  put 
up  in  a  long  plaster  spica  in  extreme  abduction.  A 
linear  osteotomy  is  often  sufficient,  but  a  wedge  should 
be  removed,  if  necessary. 

Coxa  valga  is  the  opposite  deformity,  where  the  neck- 
shaft  angle  is  increased,  the  leg  is  lengthened,  and  the 
trochanter  depressed.  It  may  occur  in  cases  of  infantile 
paralysis,   or   during   other   affections,   where    the    leg 


268     DEFOEMITIES    OF    LOWER   EXTREMITY 

hangs  suspended  for  a  long  time.  It  is  not  practically 
important. 

Paralytic  and  Spastic  Deformities  at  the  Hip. — After  jjolio- 
myelitis,  if  all  the  hip  muscles  are  paralyzed,  there  may 
be  a  loose  joint  with  relaxed  capsule.  For  this  a  long 
splint  may  be  applied  with  a  hip  band,  to  control  rota- 
tion. A  much  commoner  deformity  is  thigh  flexion  (usu- 
ally with  abduction),  from  the  adaptation  of  the  anterior 
hip  muscles  and  ligaments  to  the  sitting  posture.  With 
this  deformity,  when  the  patient  stands  the  front  of  the 
pelvis  is  pulled  downward  by  the  shortened  structures, 
producing  marked  lordosis.  This  contraction  cannot  be 
stretched  out,  and  the  shortened  tissues  should  be  di- 
vided subcutaneously  if  the  deformity  is  moderate, 
through  an  open  cut,  if  severe.  The  structures  cut  are 
the  tensor  fasciae  latae,  the  fascia  lata  including  the  ilio- 
tibial  band  arising  from  the  front  of  the  iliac  crest,  the 
sartorius,  and  the  rectus,  or  as  many  of  these  as  may 
be  necessary  to  get  good  correction.  The  thigh,  leg,  and 
pelvis  are  then  put  up  in  a  long  plaster  spica,  with  mod- 
erate overcorrection  of  the  flexion  and  abduction,  for 
from  four  to  six  weeks;  after  this  a  brace  to  hold  the 
foot,  leg,  and  hip  in  position  is  applied,  if  necessary. 

Occasionally  the  head  of  the  femur  slips  out  posteri- 
orly, producing  a  paralytic  dislocation.  The  head  usually 
slips  back  and  forth  into  and  out  of  the  socket  on  slight 
manipulation,  and  without  pain  or  much  resistance.  In 
severe  cases  it  may  be  kept  in  place  by  stitching  a  fold 
in  the  capsule,  or  by  excising  a  piece  of  it.  The  capsule 
may  be  so  thin,  however,  as  to  make  this  procedure  un- 
successful; in  that  case,  only  refreshing  the  joint  sur- 


THE    HIP  269 

faces  to  produce  a  stiff  joint  will  keep  the  head  of  the 
femur  from  slipping. 

Spastic  adduction  of  the  hip,  usually  on  both  sides, 
is  due  to  cerebral  paraplegia  or  diplegia.  There  is  strong 
spasm  of  the  adductors,  causing  the  knees  to  rub  to- 
gether or  the  legs  to  cross,  often  with  inversion.  Stretch- 
ing is  often  unsatisfactory;  the  deformity  may  be  over- 
come, but  it  recurs.  The  same  is  true  of  tenotomy  of  the 
adductors  unless  the  overcorrection  is  severe  and  the 
fixation  long  continued.  Eobert  Jones  excises  an  inch 
or  two  of  the  contracted  adductors  between  long-jawed 
clamps.  After  this  operation,  if  the  legs  are  widely  sepa- 
rated by  a  double  spica  or  other  means  for  six  or  eight 
weeks  the  deformity  does  not  recur,  though  the  adductors 
resume  their  function. 

For  the  inversion  of  spastic  palsy  and  of  hemiplegia, 
Gibney  excises  the  tensor  fasciae  latse,  retaining  the  leg 
in  a  long  spica  in  outward  rotation  for  six  weeks. 

Diseases  of  the  Hip-Joint 

Tuberculous  hip  disease,  coxitis  tuberculosa,  comprises  about 
two  fifths  of  all  tuberculous  joint  disease;  about  ninety 
per  cent  of  all  hip  infections  in  children  are  tuberculous. 
Hip  tuberculosis  may  complicate  spinal  or  other  joint 
tuberculosis,  or  be  complicated  by  them,  but  the  large 
majority  of  cases  are  solitary  as  far  as  tuberculous  bone 
disease  is  concerned.  Double  hip  disease  is  rare,  and 
should  lead  to  a  careful  investigation  of  the  underlying 
cause,  which  may  be  pus,  syphilis,  or  arthritis  defor- 
mans. The  disease  is  commonest  in  delicate  and  poorly 
nourished  children,  but  may  occur  at  any  age.    It  may 


270      DEFORMITIES    OF    LOWER    EXTREMITY 

occur  one  to  four  months  after  an  injury  of  moderate 
severity,  also  after  measles,  whooping  cough,  and  other 
acute  infectious  diseases. 


Fig.  138  a. — Tuberculosis  of  Hip;  Slight  Lameness,  No  Pain,  Little 
Spasm,  Six  Months;  One-half  Inch  Shortening;  Boy  of  Seven.  (Hos- 
pital for  the  Ruptured  and  Crippled.) 


THE   HIP  271 

Pathological  Anatomy.— The  tuberculous  focus   is 
usually  a  secondary  infection  by  way  of  the  blood  from 


Fig.  138  5. — Tuberculosis  of  Hip  after  Measles;  Disintegration  of 
Acetabulum  and  Head  of  Femur;  Atrophy  of  Leg  and  Pelvic 
Bones;  Boy  of  Six.     (Hospital  for  the  Ruptured  and  Crippled.) 


272     DEFOEMITIES    OF    LOWER    EXTREMITY 

diseased  abdominal  or  thoracic  glands  (or  other  organs). 
These  are  often  not  evident  clinically,  and  usually  cause 
no  trouble  if  the  joint  disease  is  cured.  The  process 
usually  begins  as  isolated  or  multiple  foci  or  diifuse 
infiltration  in  the  cancellous  tissue  of  the  femoral  epiph- 
ysis or  in  the  acetabulum ;  some  authorities  claim  a  large 
percentage  of  primary  synovial  infection.  The  destruc- 
tive process  spreads  by  softening,  caseation,  and  the  for- 
mation of  ichor  pockets  (cold  abscesses)  and  small  se- 
questra; cicatrization  may  occur  at  any  stage.  Usually 
the  cartilage  is  perforated  and  tuberculous  material  in- 
fects the  joint,  causing  pulpy  degeneration  of  the  syno- 
vial membrane  and  ulceration  of  the  joint  structures 


Fig.  139. — Erosion  (Wandering)  of  Acetabulum  from  Tuberculosis  of 
THE  Hip-joint.  (From  specimens  in  the  College  of  Physicians  and 
Surgeons,  New  York.) 

(Figs.  138^  and  138  5).  The  acetabulum  is  gradually 
enlarged  ujDward  and  backward  (wandering  acetabulum) 
(Fig.  139),  and  it  and  the  head  are  eroded  by  the  tubercu- 


THE    HIP  273 

lous  process,  aggravated  by  the  pressure  of  muscle  spasm 
and  weight  bearing,  and  the  grinding  of  liip  motion.    In 


Fig.  140. — Tuberculosis  of  Trochanter  Without  Involvement  of  the 
Hip-joint;  Local  Pain,  Tenderness,  and  Swelling  Eight  Months. 
(Hospital  for  the  Ruptured  and  Crippled.) 

rare  cases  the  focus  is  in  the  great  trochanter  or  neck, 
where  it  may  break  outside  the  joint  or  be  removed  (Figs. 
140, 141,  and  142).  In  severe  cases  the  head  may  become 
dislocated  upward  and  backward,  or  be  entirely  absorbed, 
or  may  lie  in  the  joint  as  a  sequestrum.    The  process  ends 


274     DEFOEMITIES   OF   LOWER   EXTREMITY 


in  fibrous  contraction  and  adhesions,  and  mucli  more 
rarely  in  bony  ankylosis  (Fig.  143) ;  all  the  bony  as  well 
as  the  soft  parts  of  the  limb  and  corresponding  half  of 
the  pelvis  become  wasted  and  are  retarded  in  growth. 

All  the  bones  of  the 
limb  are  finally  small- 
er, shorter,  and  more 
brittle  than  those  of 
the  well  side;  the 
sound  limb  may  be 
abnormally  large  and 
muscular  from  over- 
use. Ichor  pocket 
(cold  abscess)  forma- 
tion is  common;  such 
pockets  may  present 
in  the  gluteal  region, 
but  are  more  common 
in  front  of  the  thigh 
or  at  the  outer  or  in- 
ner side;  they  occa- 
sionally break  through 
the  acetabulum  into 
the  pelvis.  They  some- 
times disappear  with- 
out treatment,  more 
often  after  aspira- 
tion; usually  they 
open  spontaneously  or  are  incised,  in  order  to  avoid 
extensive  burrowing  and  multiple  sinuses.  Abscesses 
and  sinuses  infected  with  pus  microbes  may  cause  sepsis 


L 

^gHM&.  '     '  '""'' 

Fig.  141. —  Disease  of  Great  Trochan- 
ter. (From  specimen  in  Royal  College 
of  Surgeons.     Phelps.) 


THE    HIP  275 

with  fever,  and  long-continued  profuse  suppuration  may 
cause  waxy  degeneration  of  the  viscera,  including  the 
kidneys.  A  certain  percentage  of  cases,  with  or  without 
ichor  pockets,  succumb  to  pulmonary  tuberculosis,  tuber- 
culous meningitis,  and  acute  miliary  tuberculosis. 

Symptoms. — The  invasion  is  usually  insidious;  in  a 
fair  percentage  of  cases  a  slight  or  moderate  injury  is 


Fig.  142. — ^Tuberculosis  op  Femoral  Neck  and  Top  of  Trochanter. 
Moderate  pain,  lameness  and  atrophy  after  a  fall  five  months  before; 
severe  limping  two  months;  three-quarter  inch  shortening.  Curetment 
by  Whitman.     (Hospital  for  the  Ruptured  and  Crippled.) 

followed  in  one  to  four  months  by  lameness,  usually  pain- 
less at  first.  This  lameness  may  be  slight,  and  is  usually 
intermittent;  it  may  last,  with  the  intermissions,  two  to 
six  months  before  pain  is  complained  of.    The  lameness 


276     DEFORMITIES    OF   LOWER   EXTREMITY 

is  characteristic,  and  indicates  soreness  and  an  avoid- 
ance of  weight  bearing  and  of  full  hip  motion,  particu- 
larly full  extension.    Pain  often  appears  as  restlessness 


p 

1 

^p  , 

1  ?M 

^^^^^^^^^,''S ^^^^M 

f-    i 

^^^^^^^^^H 

^^^^^^^^^^^^^^1 

BHI 

Fig.  143. — Bony  Ankylosis  of  the  Hip-joint. 
(From  specimen  in  the  College  of  Physicians  and  Surgeons.) 

or  starting  and  crying  at  night,  followed  by  acute  pain  in 
the  groin  or  knee,  which  may  become  agonizing  and  may 
prevent  locomotion.     In  many  cases,  however,  particu- 


THE   HIP 


277 


larly  when  the  hip  is  protected,  pain  is  never  severe,  and 
in  some  cases  it  is  absent.    More  constant  and  charac- 


FiG.    144. —  Testing  Hyperextension  at  the  Hip;  the  Right  Side  is 

Normal. 


Fig.    145.  —  Testing  Hyperextension  at  the   Hip;  the   Left  Side  is 
Limited;  Case  op  Beginning  Hip  Tuberculosis.     (Posed  by  Strang.) 


278     DEFOEMITIES    OF    LOWER   EXTREMITY 


teristic  of  joint  involvement  than  either  pain  or  lame- 
ness is  reflex  muscular  spasm,  which  limits  passive  hip 

motion  by  jerky  con- 
tractions. This  may 
usually  be  found  even 
in  the  intervals  of 
pain  and  lameness. 
When  the  patient  lies 
on  the  face,  with  the 
knee  flexed,  and  the 
hip  is  tested  for  mo- 
tion in  rotation  and 
hyperextension,  these, 
and  particularly  the 
latter,  will  always  be 
found  somewhat  lim- 
ited in  extent  even  in 
early  cases,  and  usu- 
ally by  jerky  contrac- 
tions (Figs.  144  and 
145).  As  the  disease 
progresses  the  thigh 
assumes  certain  char- 
acteristic postures.  In 
most  early  cases  the 
thigh  is  abducted, 
flexed,  and  everted, 
either  to  relieve  in- 
tercapsular  tension,  as 
a  result  of  reflex  spasm,  or  to  spare  the  leg  (Fig. 
146).     This  posture  may  become  extreme  and  may  per- 


FiG.  146. — Beginning  Disease  at  Left 
Hip-joint,  Showing  Abduction  and 
Eversion;  Weight  is  Borne  on  the 
Right  Leg. 


THE    HIP  279 

sist;  in  it  the  affected  limb  is  apparently  longer.  In 
most  untreated  cases  the  flexion  increases,  and  abduc- 
tion changes  to  adduction  as  the  case  progresses.  In 
such  cases  the  affected  limb  is  apparently  and  usually 


Fig.  147. — Adduction  and  Flexion  at  Left  Hip  Unmasked  by  Bringing 
Pelvis  Level,  and  Back  to  Table.     (Phelps.) 

actually  shorter.  Adduction  may  appear  early,  and 
may  be  combined  with  either  eversion  or  inversion  (Fig. 
147).  The  lateral  malpositions  cause  compensatory  lat- 
eral bending  of  the  spine,  but  seldom  true  rotary  lateral 


280      DEFORMITIES    OF   LOWER   EXTREMITY 

curvature;  thigh  flexion  produces  lordosis,  when  the 
thigh  is  brought  down  (Fig.  150).  As  the  disease  pro- 
gresses, j)ain,  spasm,  stiffness  (Figs.  148  and  149),  and 
limping  become  more  marked,  until  the  joint  is  locked, 
and  walking  is  no  longer  possible  from  malposition  or 
sensitiveness.  When  in  this  sensitive  and  helpless  con- 
dition every  movement  may  cause  pain  and  the  patient 
dreads  to  be  touched ;  he  often  presses  upon  the  dorsum 
of  the  foot  of  the  affected  side  with  the  well  foot  to  pre- 
vent motion  and  to  produce  traction,  which  also  gives 
relief  when  given  by  hand,  by  a  machine,  or  by  a  weight. 
In  long-standing  cases  atrophy  is  marked  and  the  mal- 
positions become  fixed  from  adaptation  to  posture,  from 


Fig.  148. — Testing  Flexion  op  Left  Leg. 

adhesions,  from  displacement,  and  in  a  few  cases  from 
synostosis;  the  knee  often  becomes  flexed  and  the  foot 
dropped.  In  most  cases  considerable  real  shortening 
finally  results  from  upward  and  backward  displacement 


THE    HIP  281 

due  to  erosion  of  the  head  and  acetabulum.  In  addition 
to  the  shortening  from  this  cause,  which  may  amount  to 
an  inch  or  more,  there  is  often  in  juvenile  disease  of 
lono:  standing  considerable  shortening  due  to  retarded 


Fig.  149. — Testing  Extension  of  Left  Leg.     (Posed  by  Strang.) 

growth ;  this  affects  the  whole  limb  and  the  affected  side 
of  the  pelvis,  and  in  the  course  of  several  years  may 
amount  to  two  or  three  inches,  or  more.  The  tibia  alone 
may  be  an  inch  or  more,  and  the  foot  nearly  or  quite 
an  inch,  shorter  than  its  mate.  In  a  few  cases  growth 
in  length  does  not  seem  to  be  affected.  In  about  one 
fifth  of  the  treated  cases  ichor  pockets  develop.  Pallor, 
emaciation,  and  loss  of  appetite  are  common  after  the 
earliest  stages,  but  fever  above  99.5°  is  rare,  unless  in- 
fection by  pus  microbes  has  occurred. 

The  DIAGNOSIS  as  to  location  is  easy  when  the  disease 
is  pronounced;  early  cases  are  usually  brought  on  ac- 
count of  lameness.    Children  should  be  entirely  undressed 

20 


282     DEFORMITIES    OF    LOWER    EXTREMITY 

and  their  gait  and  movements  studied;  the  hip  should 
then  be  systematically  tested  in  walking,  standing,  re- 
cumbency, and  procumbency,  for  posture,  motion,  and 
muscular  spasm;  the  length  and  circumference  of  the 
limbs  should  be  measured,  and  the  position  of  the  great 
trochanter  tested  with  reference  to  Nelaton's  line;  this 
line  is  drawn  by  a  string  from  the  anterior  superior  iliac 
spine  to  the  tuberosity  of  the  ischium,  and  the  normal 
trochanter  does  not  rise  above  it.  The  joint  should  also 
be  palpated  for  tenderness,  tension,  and  swelling,  but 
forcible  movements  and  pounding  upon  the  sole  or  other 
violent  means  to  elicit  pain  are  to  be  condemned.  While 
implication  of  the  hip- joint  is  usually  readily  made  out, 
it  is  often  not  so  easy  to  establish  the  pathological  diag- 
nosis. A  tuberculin  test  is  sometimes  helpful.  Dis- 
ability following  directly  upon  an  injury  is  usually  due 
to  lesion  of  the  parts,  such  as  sprain,  or  fracture  of  the 
neck  of  the  femur. 

Acute  invasion,  with  high  fever,  pain,  local  tender- 
ness, and  thickening,  is  usually  due  to  osteomyelitis  of 
the  upper  end  of  the  shaft.  In  cachectic  infants  a  fluc- 
tuating joint,  with  fever,  often  denotes  a  suppurative 
arthritis.  In  middle-aged  and  elderly  people  a  stiff  and 
painful  affection  of  the  hip,  coming  on  slowly  with  no 
tendency  to  suppurate,  is  usually  senile  osteoarthritis. 
Lameness  and  elevation  of  the  trochanter,  coming  on 
slowly  with  pain  and  some  stiffness,  particularly  limita- 
tion of  abduction  and  inversion  in  flabby  youths,  may  be 
due  to  coxa  vara. 

Congenital  dislocation  of  the  hip  and  infantile  paral- 
ysis should  not  be  mistaken  for  hip  disease,  though  the 


THE    HIP  283 

writer  lias  known  a  case  of  paralysis  to  be  treated  for  a 
year  for  hip  tuberculosis.  Many  hip  infections  are  not 
easily  distinguished  clinically  from  tuberculosis,  and  one 
is  obliged  to  rely  largely  on  the  history  of  preceding  dis- 
ease. A  considerable  number  of  cases  of  hip  infection 
in  youths  and  young  adults  are  gonorrheal. 

The  absence  of  joint  spasm,  the  freedom  of  all  move- 
ments except  extension  and  internal  rotation,  and  the 
presence  of  Pott's  disease  will  serve  to  distinguish  psoas 
contraction.  In  sacro-iliac  disease,  passive  hip  motions 
with  the  knee  flexed  are  usually  free.  Skiagraphy  fre- 
quently^, and  aspiration  occasionally,  may  aid  in  the 
diagnosis. 

The  TREATMENT,  as  ill  other  tuberculous  affections, 
is  by  general  invigoration  and  by  enforced  rest  and  pro- 
tection to  the  joint.  The  joint  must  be  immobilized  and 
relieved  of  weight  bearing,  and  protected  against  spasm 
and  other  injury.  If  the  patient  is  old  enough  to  lie  still, 
traction  in  bed  by  means  of  a  weight  and  pulley,  with  or 
without  a  traction  splint,  is  the  treatment  of  choice  for  a 
month  or  two  until  pain  and  spasm  are  relieved.  If  the 
leg  is  flexed,  it  should  be  elevated  on  an  inclined  plane, 
and  traction  made  in  the  line  of  the  deformity  (Figs.  150 
and  151).  With  this  precaution,  traction  in  bed  nearly 
always  affords  prompt  relief  to  the  pain,  and  more  slowly 
brings  the  leg  into  good  position.  Five  to  eight  pounds 
are  usually  sufficient  for  a  child.  If  pain  and  spasm  are 
not  relieved  by  recumbency,  with  traction  properly  ap- 
plied, there  is  either  tension  from  fluid  in  the  joint  or  the 
disease  is  in  part  extra-articular.  In  very  young  children 
the  best  first  dressing  is  a  long  plaster-of -Paris  spica,  put 


Fig.  150. — Case  of  Hip  Tuberculosis  Prepared  for  Traction  in  Bed. 

Note  lordosis. 


Fig.  151. — -Traction   in  Bed  with  Weight  and    Pulley;  Post-graduate 
Hospital.     Note  disappearance  of  lordosis  when  leg  is  elevated. 
284 


THE    HIP 


285 


on  with  traction  of  the  leg,  reaching  from  the  ensiform 
cartilage  to  the  toes,  and  snugly  grasping  the  pelvis. 
In  dispensary  cases  without  marked  deformity,  the  long 
plaster  spica  may  take  the  place  of  traction  in  bed. 

When  the  acute  symptoms  have  subsided,  or  before,  a 
rigid  immobilizing  and  traction  splint  with  a  thoracic  at- 
tachment should  be  fitted, 
and  worn  day  and  night. 
Perineal  straps,  to  fur- 
nish countertraction  and 
to  carry  the  weight  of  the 
body,  are  attached  to  the 
hip  band  (C.  F.  Taylor), 
or  the  weight  may  be 
borne  on  a  padded  ring 
(Phelps)  (Fig.  152).  The 
splint  is  longer  than  the 
limb  by  two  and  a  half 
inches,  and  its  lower  end 
rests  on  the  ground;  it  is 
attached  by  straps  to  the 
buckles  of  the  adhesive 
plaster,  which  has  pre- 
viously been  applied  to 
the  leg.  A  ratchet  is  con- 
venient for  adjustment, 
but  if  the  straps  are  kept 
tight  and  a  weight  is  at- 
tached to  the  splint  at 
night,  it  is  not  essential, 
be  applied  to  the  top  of  the  thigh,  and  the  knee  should 


Fig.  152. — Phelps's  Hip-splint,  with 
Crutches  and  High  Shoe  on  Well 
Foot,  as  Used  at  the  Post-Gradu- 
ATE  Hospital. 

The  adhesive  plaster  should 


286      DEFOEMITIES    OF    LOWEE    EXTREMITY 

be  supported  behind,  in  order  to  prevent  relaxation 
and  recurvature  (Fig.  153),  The  child  wears  a  two- 
and-one-half-inch  cork  sole  on  the  well  foot,  and  the  use 


Fig.  153. — Method  of  Applying  Adhesive  Plaster  for  Hip  Traction. 
Fixation  and  suspension  splint  used  at  the  Hospital  for  Ruptured  and 
Crippled. 


of  crutches,  at  least  during  the  acute  stage,  is  desirable ; 
exercise  should  be  greatly  limited  and  jolting  avoided. 


THE    HIP 


287 


Particular  attention  is  paid  tlirougliout  the  treatment 
to  the  prevention  and  correction  of  deformity.     Under 


Fig.  154. — Fibrous  Ankylosis 
OF  THE  Right  Hip  at  a  Right 

Angle. 


Fig.  155. — Same  Patient  as 
Fig.  154.  Result  after  ma- 
nipulation under  ether. 


careful  management  serious  deformity  should  not  occur, 
but,  when  present,  it  should  be  corrected.  The  devia- 
tions due  to  muscular  spasm  disappear  under  anesthesia. 


288      DEFOBMITIES    OF    LOWER    EXTREMITY 

and  may  usually  be  stretched  out  by  traction  in  bed.  In 
the  later  stages,  a  year  or  more  after  the  subsidence 
of  acute  symptoms,  fibrous  adhesions  may  be  caref^Uly 
broken  up  under  anesthesia,  flexion  and  adduction  over- 
come, and  the  leg  placed  in  extension  and  moderate  ab- 
duction in  a  long  plaster  spica  (Figs.  154  and  155).  In 
correcting  these  cases  the  pelvis  may  be  fixed  by  extreme 
flexion  of  the  sound  thigh,  or  by  a  temporary  short  spica 
reaching  to  the  knee  of  the  well  side  (Dollinger).  Owing 
to  the  atrophy  of  the  femur  a  fracture  is  easily  produced, 
unless  the  manipulations  are  made  slowly,  and  with  care. 
If  a  fracture  should  occur  near  the  joint,  the  opportunity 
should  be  utilized  to  correct  the  deformity  by  placing  the 
thigh  in  extension  and  abduction,  and  retaining  the  pos- 
ture by  a  long  spica ;  usually  no  harm  results.  After  the 
correction  of  a  hip  deformity  the  long  spica  should  be 
worn  for  eight  or  ten  weeks;  it  is  then  replaced  by  a 
short  spica,  high  sole,  and  crutches,  which  may  be  re- 
newed several  times  until  the  hip  is  stable  in  the  posture 
of  choice. 

Gant's  Osteotomy. — In  stiff,  cured  cases,  with  adduc- 
tion and  flexion,  the  deformity  should  be  corrected  and 
the  leg  restored  to  usefulness  by  a  subcutaneous  linear 
osteotomy  just  below  the  trochanter  minor  (Gant).  This 
operation,  which  should  be  postponed  until  sinuses  are 
healed,  is  not  difficult  or  dangerous,  and  gives  excellent 
results,  often  adding  two  or  three  inches  to  the  effective 
length  of  the  leg.  The  operation  may  be  done  through 
an  open  incision,  if  preferred.  The  subcutaneous  opera- 
tion is  as  follows :  The  anesthetized  patient  is  placed  on 
the  well  side,  with  a  sand  bag  between  the  thighs  as 


THE    HIP  289 

high  up  as  possible,  and  a  sharp  osteotome  one  quarter 
to  three  eighths  inch  wide  is  pushed  through  the  skin  to 
the  bone  in  the  axis  of  the  femur.  After  the  periosteum 
is  divided  the  edge  of  the  osteotome  is  turned  across  the 


Fig.  156.  —  Result  after  Gant's  Osteotomy  (Albee)  for  Perala.nent 
Adduction  of  the  Thigh.  Girl  of  sixteen  whose  coxitis  was  cured  with- 
out mechanical  treatment. 


290     DEFORMITIES    OF    LOWER    EXTREMITY 

axis  of  the  femur,  and  the  shaft  divided  by  blows  of  a 
mallet  for  two  thirds  or  three  quarters  of  its  extent. 
The  osteotome  is  then  withdrawn,  the  femur  fractured, 
and  the  thigh  brought  into  extension  and  abduction ;  one 
catgut  suture  closes  the  tiny  wound,  and  a  gauze  and 
cotton  dressing  and  long  plaster  spica  are  applied.  The 
after  treatment  is  the  same  as  after  manual  correction 
(Fig.  156). 

A  few  early  cases  of  coxitis,  thought  to  be  tubercu- 
lous, recover  in  a  year  or  less;  in  many  of  these  the 
diagnosis  is  doubtful.  In  most  really  tuberculous  cases 
several  years  of  mechanical  support  will  be  required. 
"When  convalescence  is  established  the  thoracic  attach- 
ment may  be  removed,  the  toes  may  be  allowed  to  touch 
the  ground,  a  jointed  supporting  splint  may  be  applied, 
or  the  child  may  be  allowed  to  walk  in  a  short  spica, 
grasping  the  pelvis  and  extending  only  to  the  knee.  When 
the  time  comes  to  discontinue  support,  the- splint  should 
be  at  first  left  off  at  night  and  later  gradually  discon- 
tinued during  the  day.  Some  patients  are  kept  far  too 
long  in  splints,  while  in  others  the  splints  are  removed 
too  early;  either  error  is  a  costly  one,  and  the  matter 
is  one  for  careful  consideration  and  ripe  judgment. 

Ichor  pockets,  so  long  as  they  are  not  infected,  are 
usually  harmless ;  for  this  reason  they  should  be  treated 
with  great  conservatism.  When  small  they  should  be 
let  alone;  they  sometimes  disappear.  If  they  increase 
in  size  and  threaten  to  burrow,  they  should  be  aspirated 
through  a  large  needle,  and  this  should  be  repeated 
at  intervals  of  a  week  or  two;  a  fair  number  dis- 
appear under  this  treatment.    If  in  spite  of  aspiration 


THE    HIP  291 

tliey  increase  and  require  treatment,  they  may  be  asep- 
tically  incised  and  drained,  and  left  open  or  sutured. 
Many  contract,  and  heal  at  once  or  after  discharging 
for  a  longer  or  shorter  time,  especially  if  fresh  air,  feed- 
ing, and  joint  rest  are  attended  to.  Others  burrow  in 
spite  of  care,  and  finally  end  in  one  or  many  more  or 
less  infected  sinuses,  which  are  often  troublesome,  and 
may  be  dangerous.  Multiple  and  intractable  sinuses  are 
apt  to  result  from  disease  of  the  shaft  or  pelvis,  com- 
plicating the  original  trouble.  Sinuses  should  not  be  al- 
lowed to  pocket,  and  should  freely  drain  the  site  of  dis- 
ease. The  washing  and  injection  of  pockets  and  sinuses, 
except  to  clean  up  a  pus  infection,  is  usually  useless 
and  often  harmful,  though  an  occasional  small  injection 
of  a  saturated  solution  of  iodoform  in  ether  or  a  ten- 
per-cent  emulsion  of  iodoform  in  pure  glycerin  i^to  old 
sinuses  is  sometimes  advantageous.  The  scraping  out 
of  pockets  has  given  very  bad  results  in  practice.  When 
extensively  undermined,  it  is  sometimes  necessary  to  lay 
open  these  cysts  by  long  incisions,  and  allow  them  to 
granulate.  As  a  rule,  if  the  general  and  local  treatment 
is  well  attended  to,  the  less  uninfected  pockets  are  inter- 
fered with  the  better ;  when  infected  they  should  be  freely 
opened,  washed  out,  and  kept  aseptic.  The  bismuth- 
vaselin  injections  are  beneficial  in  many  cases  of  pockets 
and  sinuses  (see  General  Part). 

Operative  Treatment. — After  extensive  trial,  early 
excisions  and  erasions  for  tuberculous  joint  disease  have 
been  abandoned  in  children;  they  are  now  reserved  for 
cases  in  which  conservative  treatment  has  failed,  and 
are  indicated  in  only  a  small  percentage.    Statistics  show 


292     DEFOEMITIES    OF   LOWEE   EXTEEMITY 

a  mortality  from  the  operation  or  from  the  disease  after 
operation  of  nearly  one  half.  In  those  who  recover,  the 
limb  is  often  very  poor.    In  adults,  excision  is  often  the 


Fig.  157. — Result  after  Excision  of  the  Hip;    Boy  of  Twelve;   Cure 
WITH  Flexion  and  Shortening.     The  flexion  should  be  corrected. 


operation  of  choice,  and  frequently  gives  excellent  re- 
sults. As  the  patient  is  usually  in  poor  condition,  it 
is  important  to   do  the  operation  quickly.     An  ample 


THE    HIP  293 

incision  is  made  from  above  the  acetabulum  to  below 
the  trochanter  and  into  the  joint,  the  capsule  is  sepa- 
rated, the  neck  or  trochanter  is  quickly  chiseled  off,  and 
the  head  removed  with  the  forceps.  Diseased  bone  is 
scraped  out  with  the  curette,  and  as  much  as  possible 
of  the  diseased  capsule  is  removed  by  curved  scissors. 
The  joint  is  washed  out  with  hot  saline  and  packed 
tightly  for  twenty-four  hours,  then  down  to  bone  only, 
and  healing  is  by  granulation;  sinuses  often  persist 
(Fig.  157). 

Peognosis. — Many  untreated  or  neglected  cases  of 
tuberculous  coxitis  succumb  after  a  longer  or  shorter 
period  to  tuberculous  and  septic  accidents,  waxy  degen- 
eration, renal  involvement,  prolonged  suppuration,  or  ex- 
haustion. In  others,  after  the  disease  has  run  its  course, 
the  patient  is  left  in  fairly  good  general  condition,  but 
with  a  stiff,  flexed,  adducted,  inverted,  and  shortened 
leg,  rendering  locomotion  difficult  or  impossible  (Fig. 
158).  In  females,  the  deformity  may  be  a  bar  to  mar- 
riage and  maternity.  These  deformities,  no  matter  how 
severe  or  of  how  long  standing,  may  be  corrected  by 
Gant's  osteotomy,  as  already  described.  In  hygienically 
and  mechanically  treated  cases  the  suffering  and  mor- 
tality are  diminished,  the  complications  are  less  serious, 
and  the  final  usefulness  of  the  limb  greater.  The  large 
majority  recover  with  a  competent  limb,  many  with  ex- 
cellent motion.  Unless  the  leg  is  left  in  good  posture, 
the  result  is  not  to  be  considered  satisfactory.  Relapses 
are  possible,  even  after  many  years,  from  sickness  or 
injury,  owing  to  the  freeing  of  encapsulated  bacteria, 
but  this  only  occurs  in  a  small  proportion. 


294     DEFOEMITIES    OF    LOWER    EXTREMITY 

Infections  of  the  hip-joint  may  be  produced  by  pus  cocci 
and  other  microbes,  such  as  gonococci,  pneumococci,  and 


Fig.  158.  —  Natural,  Cure  of  Coxitis.  Disease  at  ten;  extensive  sinuses 
closed  after  one  year.  At  twenty  there  were  extreme  flexion  and  adduc- 
tion, which  was  corrected  mechanically  by  C.  F.  Taylor.  The  skiagram 
taken  at  fifty-three  shows  excellent  posture,  disappearance  of  head  and 
upward  displacement.  There  is  shortening  of  three  inches,  over  ninety 
degrees  of  motion,  and  excellent  function. 


typhoid  bacilli;  these  sometimes  cause  suppuration,  at 
other  times  effusion  or  adhesive  inflammation.  The  in- 
fection is  usually  brought  by  the  blood  current  from  some 


THE    HIP  295 

local  focus,  but  may  arise  from  contiguity  or  from  direct 
infection.  The  symptoms  of  pus  infection,  which  may  be 
primarily  synovial  or  osteal,  are  acute  and  severe ;  after 
confirmation  of  the  diagnosis  by  aspiration,  purulent 
synovitis  requires  aseptic  incision,  irrigation  of  the  joint, 
and  drainage;  bone  operations  will  be  required  in  the 
osteal  form. 

Bacterial  products  may  produce  joint  irritation  with- 
out suppuration,  but  with  pain,  tenderness,  swelling, 
stiffness,  and  disability  lasting  a  longer  or  shorter  time. 
Such  cases  were  formerly  called  rheumatic,  but  may 
often  be  traced  to  a  definite  source  of  infection,  such 
as  the  tonsils  or  alimentary  canal,  and  are  amenable 
to  treatment.  The  toxemia  should  be  combated  if 
still  present,  and  its  source  eradicated  or  sterilized; 
during  the  active  stages  the  affected  joints  should  be 
put  at  rest  by  recumbency,  and,  if  necessary,  by  traction 
and  splints.  During  the  stage  of  convalescence  general 
tonic  measures  and  local  stimulation  by  vibration,  mas- 
sage, heat,  electricity,  and  graduated  exercise  may  be 
employed,  and  the  protected  or  limited  use  of  the 
joint  favored  by  special  apparatus,  which  enable  the 
patient  to  walk  without  strain  or  injury  to  the  weak- 
ened part. 

The  SUPPURATIVE  COXITIS  (epiphysitis)  of  Iiq-FANCY 
usually  occurs  during  the  first  year,  and  is  often  fatal 
unless  prompt  surgical  relief  is  afforded.  The  head  of 
the  femur  may  be  destroyed,  or  it  may  have  to  be  re- 
moved, and  the  patient  in  such  cases  recovers  with  a 
loose  joint  and  upward  displacement  of  the  femur  (Fig. 
159). 


296     DEFORMITIES    OF   LOWER   EXTREMITY 

GoNOKEHEAL  COXITIS  is  not  UQConimon  in  young  adults. 
Many  of  these  patients  seem  perfectly  healthy,  and  no 
source  of  infection  is  found  until  the  genito-urinary  con- 
dition and  history  are  investigated.     Other  joints  may 


Fig.  159. — -Disappearance  op  Head  and  Neck  of  Femur  from  Suppura- 
tive Arthritis  at  One  and  a  Half  Years.     Boy  of  Six. 


or  may  not  be  affected.  The  coxitis  often  causes  great 
suffering  and  disability,  which  may  oblige  the  patient 
to  go  to  bed.  With  proper  treatment  of  the  source  of  in- 
fection, rest,  and  traction,  the  aifection  usually  goes  on 


THE    HIP  297 

to  recovery  in  far  less  time  and  with  less  local  damage 
than  do  the  tuberculous  cases.  Stiffness  not  infrequently 
follows,  and  it  is  important  to  keep  the  thigh  extended 
and  abducted.  If  the  patient  recovers  with  ankylosis 
and  deformity,  they  may  be  rectified  by  a  forcible  stretch- 
ing or  an  osteotomy. 

Aktheitis  deformans  is  usually  polyarticular,  par- 
ticularly affecting  the  phalangeal  joints,  but  often  in- 
volves one  hip  or  both,  and  other  large  joints.  It  is 
characterized  by  atrophy  of  bone  cartilage  and  soft  parts, 
joint  stiffness,  and  deformation.  The  general  manage- 
ment of  the  condition  is  described  in  the  general  section 
(p.  45),  and  one  should  not  take  too  pessimistic  a  view. 
Some  cases  do  not  progress  far,  others  are  arrested  by 
treatment,  while  nearly  all  are  susceptible  of  improve- 
ment. The  local  treatment  by  rest  and  prevention  of 
deformity  in  the  active  stage,  and  by  stimulation  and 
correction  of  deformity  in  the  stage  of  convalescence, 
gives  gratifying,  and  sometimes  brilliant,  results.  The 
plight  of  patients  with  both  hips  or  other  major  joints 
stiff  is,  indeed,  a  sad  one,  and  in  such  cases  the  attempt 
may  be  made  to  mobilize  the  joints  by  judicious  and 
not  too  strenuous  manipulation.  If  this  fails,  a  flap 
of  fat  and  fascia  may  be  introduced  into  the  joint 
(Murphy),  or  the  attempt  may  be  made  to  obtain  a 
pseudarthrosis. 

Osteoarthritis  of  the  Hip  and  Senile  Coxitis. — 
There  is  a  lesion,  often  monarticular,  which  frequently 
attacks  the  hip,  especially  in  middle  life  or  beyond,  which 
causes  pain,  stiffness,  and  lameness  usually  without  con- 
stitutional symptoms,  and  which  may  make  walking  very 

31 


298     DEFORMITIES    OF   LOWER   EXTREMITY 

difficult  or  impossible.    It  usually  comes  on  slowly,  some- 
times after  an  injury,  and  is  characterized  by  the  wear- 


FiG.  160. — Osteoarthritis  op  the  Hip,  Anterior  View  Except  Specimen 
TO  Right,  which  is  Seen  From  Behind.  (From  specimens  in  Cornell 
Medical  College.) 


ing  away  of  the  weight-bearing  parts  of  the  joint  and 
the   formation    of   osteophytes    around    the    periphery. 


THE    HIP  299 

The  head  often  becomes  cylindrical,  limiting  motion  to 
flexion  and  extension,  the  plan  of  which  may  be  deflected 
(Fig.  160).  There  is  no  tendency  to  suppuration.  The 
thigh  usually  becomes  flexed  and  adducted. 

The  affection  may  also  be  polyarticular,  when  the 
lumbar  spine,  iliac  joints,  hips,  and  knees  are  specially 
liable  to  involvement,  though  the  small  joints  are  not 
immune.  In  a  few  cases  striking  benefit  has  been  ob- 
tained by  the  use  of  deep  vibration  about  the  hip-joint. 
As  the  condition  is  much  aggravated  by  friction  and 
pressure,  the  use  of  a  short  spica  and  crutches,  or  of  a 
jointed  supporting  splint,  after  preliminary  traction  in 
bed,  is  sometimes  of  great  benefit,  and  the  disease  may 
be  arrested.  In  some  cases  the  suffering,  malposition, 
and  disability  are  so  great  as  to  justify  a  radical 
operation. 

The  head  of  the  femur  and  the  roof  of  the  acetabulum 
may  be  chiseled  flat  and  brought  together  (Albee),  in 
order  to  give  a  firm  and  stable  ankylosis  in  good  pos- 
ture; this  has  worked  admirably  in  eight  cases  in  which 
it  has  been  tried. 

Albee' s  Operation. — The  hip  is  reached  by  an  ante- 
rior incision  five  inches  long  from  the  anterior  superior 
spine  of  the  ilium,  downward  along  the  inner  border 
of  the  sartorius  muscle,  which  is  retracted  outward. 
The  muscles  and  deep  structures  are  separated  by 
blunt  dissection.  The  iliacus  and  the  rectus  femoris 
muscles  are  retracted  inward.  Osteophytes  about  the 
acetabulum,  if  numerous,  should  be  turned  aside  with  the 
soft  tissues  adherent  to  them,  on  account  of  their  bone- 
forming  possibilities.    The  joint,  which  is  often  obscured 


300     DEFORMITIES    OF   LOWER   EXTREMITY 

by  these  bony  excrescences,  should  be  definitely  located 
before  the  partial  removal  of  the  head  is  begun.  With 
the  leg  adducted,  about  one  half  of  the  upper  hemisphere 
of  the  head  of  the  femur  is  removed  in  situ  with  a  large 
chisel  through  a  plane  nearly  parallel  to  the  long  axis 
of  its  neck.    With  the  same  instrument  the  acetabulum 


Fig.  161. — Diagram  of  Albee's  Operation.  The  broken  lines  indicate  the 
amount  of  bone  to  be  removed.  It  is  removed  from  the  head  and  the 
acetabulum  in  different  planes,  in  order  to  secure  the  desired  abduction  of 
the  thigh  when  the  bone  surfaces  are  brought  together. 

is  transformed  into  a  flat  roof,  against  which  the  fresh 
surface  of  the  head  is  brought  into  firm  contact  by  ab- 
duction of  the  thigh.    In  order  to  prevent  slipping,  the 


THE    HIP  301 

acetabular  roof  slopes  slightly  outward  (Figs.  161  and 
162).  The  capsule  and  soft  tissues  are  sutured  while  the 
leg  is  held  in  strong  abduction.    If  this  position  is  pre- 


FiG.  162. — Diagram  of  Albee's  Operation.     Apposition  of  the  cut  surfaces 
after  the  removal  of  the  bone  from  the  head  and  the  acetabvilum. 


vented  by  contractures  of  the  adductor  muscles,  tenot- 
omies of  those  muscles  may  be  necessary.  The  leg  is 
finally  put  up  in  a  spica,  from  axilla  to  toes,  in  a  position 
of  marked  abduction.  The  patient  should  be  kept  in  bed 
for  three  weeks.  A  short  spica  can  usually  be  applied 
at  the  end  of  the  fifth  week,  which  should  be  retained 
six  weeks. 


302     DEFORMITIES    OP   LOWEE   EXTREMITY 

DEFORMITIES  OF  THE  LEG 

Neck  of  Femue 

Fracture  of  the  neck  of  the  femur  is  such  a  common  cause 
of  deformity  and  disability  that  it  requires  notice  here. 
This  injury  is  unfortunately  frequently  overlooked,  but 
the  disability,  hip  pain,  and  limitation  of  motion,  with 
shortening  of  the  leg,  eversion,  and  elevation  of  the  tro- 
chanter, should  make  the  diagnosis  easy,  whether  crepi- 
tus is  elicited  or  not.  Under  the  conventional  treatment 
with  sand  bags  or  weight  and  pulley,  deformity  and 
shortening  are  the  rule,  bony  union  is  the  exception,  and 
a  fatal  result  is  not  rare.  The  bone  should  be  replaced 
under  anesthesia  by  manual  traction  and  forced  abduc- 
tion, making  sure  that  the  trochanter  is  brought  down 
to  Nelaton's  line,  and  the  pelvis  and  leg  should  be  put 
up  in  a  long  spica  in  extension  and  forced  abduction 
with  correction  of  the  eversion  (Whitman).  Many  cases 
unite  under  this  treatment.  The  forced  abduction  treat- 
ment may  be  tried  in  the  first  three  months,  but  in  the 
older  cases  it  is  often  best  to  enter  the  hip-joint  through 
an  anterior  incision  on  the  inner  edge  of  the  tensor  fascias 
latae,  freshen  the  edges  of  the  fracture,  place  the  frag- 
ments in  position,  unite  the  periosteum  by  sutures  or  nail 
them  by  a  steel  drill  or  nail  driven  through  the  trochan- 
ter. The  wound  is  sutured,  but  the  nail  should  be  re- 
moved through  a  small  incision  at  the  end  of  four  weeks. 
If  the  proximal  fragment  is  small  it  is  better  to  remove 
it,  freshen  the  acetabulum  and  the  neck,  and  place  the 
neck  in  the  acetabulum,  put  the  pelvis  and  leg  in  a 


THE    FEMUR  303 

plaster  spica  in  abduction,  and  try  to  get  ankylosis  or 
adhesions  sufficient  to  keep  it  in  place;  or  an  operation 
may  be  done  similar  to  Albee's  for  senile  coxitis.  Good 
results  are  also  reported  from  spiking  without  arthrot- 
omy,  and  from  arthrotomy  without  nailing.  The  leg 
should  always  be  put  up  in  forced  abduction. 

Affections  of  the  Shaft  of  the  Femur 

Congenital. — The  femur  may  be  congenitally  absent, 
deformed,  or  short  (Fig.  163).  If  there  is  a  shortening 
of  about  an  inch  in  one  femur  in  a  young  child,  with  no 
other  objective  signs,  and  no  history  of  disease  or  in- 
jury, the  case  is  probably  one  of  congenital  shortening 
(phocomelia).  In  such  cases  motion  is  free,  the  head 
of  the  femur  is  in  the  acetabulum,  the  trochanter  may 
not  be  elevated,  and  the  leg  is  normally  developed.  The 
only  symptoms  are  a  slight  limp  if  the  shortening  is 
considerable,  and  an  inclination  of  the  pelvis  to  the  short 
side,  with  consequent  bending  of  the  spine.  The  differ- 
ence in  the  length  of  the  limbs  should  be  made  up  by  a 
cork  sole  on  the  shoe  of  the  short  side.  If  the  femur  is 
a  mere  rudiment,  walking  may  still  be  possible  if  a 
Thomas  knee  splint  is  applied  equal  in  length  to  the 
other  extremity  and  taking  the  weight  on  the  ring. 

Unequal  Growth  of  the  Limbs. — Differences  in  length  of 
the  lower  limbs  not  due  to  disease  or  deformity,  and 
amounting  to  one  quarter  or  half  an  inch,  are  not  infre- 
quently found,  particularly  in  scoliotic  girls;  the  left 
leg  is  usually  the  shorter.  It  is  not  known  which  long 
bone  is  most  affected.  There  is  usually  a  bending  of 
the  lower  spine  toward   the   short  side,   which   in   the 


304     DEFORMITIES    OF   LOWER   EXTREMITY 

yoimger  cases  wholly  or  largely  disappears  when  the 
difference  is  made  up  by  placing  some  flat  object  of 
equal  thickness,  like  a  magazine  or  thin  board,  under 


Fig.  163. — Congenitally  Short  Leg  (Phocomelia)  in  a  Baby  Fourteen 
Months  Old;  the  Shortening  is  Particularly  Marked  in  the  Femur. 

the  short  limb.  The  compensatory  bending  does  not  usu- 
ally result  in  severe  fixed  curvatures,  but  these  some- 
times occur.  The  curvature  is  not  always  toward  the 
side  of  the  short  limb.  It  is  difficult  to  assign  any  cause 
for  this  difference  except  unequal  growth,  though  some 


THE    FEMUR  305 

cases  may  be  due  to  slight  poliomyelitis.  During  the 
growing  period  the  difference  should  be  equalized  by  a 
corresponding  thickness  of  cork  under  the  shoe.  Excess- 
ive growth  of  one  leg  (macromelia)  also  occurs;  such 
legs  are  larger  as  well  as  longer. 

Osteomyelitis  of  the  shaft  is  commonest  at  the  ends  of 
the  diaphysis  (metaphysis)  and  during  the  period  of 
growth;  the  hip  and  knee  are  frequently  involved  by 
contiguity  or  perforation.  This  accident  should  be  pre- 
vented by  early  diagnosis  and  timely  operative  inter- 
ference. The  circumscribed  form  of  osteomyelitis  is 
sometimes  called  bone  abscess;  it  may  be  acute,  but  is 
occasionally  very  chronic,  and  may  run  its  course  with- 
out suppuration,  and  producing  a  cavity  with  thickened 
walls  containing  fluid,  *which  may  be  sterile.  Such  a 
lesion  is  called  a  quiet  hone  abscess,  or  Brodie's  abscess. 
It  is  sometimes  difficult  to  distinguish  from  'a  benign 
bone  cyst,  which,  however,  is  more  regular  in  outline, 
is  often  lined  with  smooth  membrane,  and  is  not  inclosed 
in  thickened  bone.  A  large  part  or  the  whole  of  the 
shaft  may  be  involved  from  the  start.  In  such  cases  the 
shaft  should  be  converted  into  a  gutter  by  chiseling  away 
its  outer  wall,  or,  if  the  shaft  is  already  dead,  it  should 
be  removed;  both  operations  should  be  done  under  the 
periosteum. 

Sarcoma  may  occur  at  either  end  of  the  femur  or  in 
the  middle.  It  prefers  the  more  rapidly  growing  end  of 
a  long  bone.  When  it  involves  the  middle  of  the  shaft 
it  is  usually  of  the  round  or  spindle-celled,  periosteal 
type,  which  is  more  malignant  than  the  giant-celled, 
medullary  type  (Fig.  30).    Sarcoma  at  the  ends  of  the 


306     DEFOEMITIES   OF   LOWER   EXTREMITY 

long  bones  may  simulate  or  provoke  joint  disease.  Ski- 
agraphy often  assists  the  diagnosis,  but  excision  and 
pathological  examination  of  a  piece  of  the  tumor  is  fre- 
quently necessary.  The  treatment  is  excision  through 
healthy  tissue  or  at  the  proximal  joint.  Injections  of 
the  mixed  toxins  of  erysipelas  and  bacillus  prodigiosus 
(Coley)  have  been  successful  in  a  few  cases,  some  of 
them  inoperable. 

Benign  cysts  of  the  femur  are  rare.  They  usually  occur 
in  youths,  and  at  the  upper  end  of  the  shaft  (Fig.  29). 
They  are  of  regular  outline,  filled  with  clear  sterile  fluid, 
and  lined  with  smooth  walls  (membrane) ;  surrounding 
bone  is  not  thickened.  If  extensive  they  may  lead  to 
spontaneous  fracture,  which,  however,  usually  unites  un- 
der proper  splinting.  Such  bone  cysts  are  benign,  and 
heal  kindly  when  scraped  out. 

Bowed  remnr. — The  femur  often  becomes  bowed,  usu- 
ally outward  and  forward,  in  rickets,  and  also  in  Paget's 
disease  (Fig.  57).  As  this  deformity  is  not  disabling, 
and  is  not  noticeable  under  the  clothing,  it  is  usually 
left  untreated. 

Flexed  Femur. — In  flexion  of  the  knee,  occurring  after 
excision,  the  bending  is  sometimes  in  the  shaft  just  above 
the  condyles.  It  may  be  corrected  by  a  cuneiform  oste- 
otomy.   See  remarks  on  the  treatment  of  flexed  knee. 

Deformities  or  the  Knee 
Congenital  Deformities 

Congenital  flexion  is  occasionally  noticed  in  babies;  it 
may  occur  on  one  or  both  sides.    In  the  light  and  middle 


THE    KNEE 


307 


grades  it  yields  to  daily  stretching  (Fig.  164).  The  severe 
forms  may  be  associated  with  pes  calcaneus,  and  may  be 
very  resistant,  sometimes  requiring  tenotomy  of  the  ham- 
strings, forcible  stretching,  and  retentive  apparatus. 


Fig.  164. — Congenital  Flexion  op  Knees  in  a  Child  of  Two. 

A  snapping  or  clicking  knee  is  occasionally  seen  in  young 
babies.     There  appears  to  be  laxity  of  the  ligaments; 


308     DEFORMITIES    OF   LOWEE   EXTREMITY 

this  permitted  a  partial  dislocation  of  the  tibia  outward 
in  a  recent  case.  The  laxity  may  be  congenital.  Bandag- 
ing, strapping,  or  splinting  usually  overcomes  the  dif- 
ficulty. 

Congenital  Hyperextension  of  the  Knee.  {Congenital  genu 
recurvatum.  Congenital  absence  of  the  patella.  Con- 
genital dislocation  of  the  knee.) 

In  this  aifection  the  baby  is  usually  born  breech  first, 
with  the  thighs  flexed  on  the  abdomen,  the  knees  hyper- 
extended,  and  the  feet  beside  the  face;  unilateral  cases 
also  occur;  the  deformity  is  evidently  due  to  uterine 
pressure  on  the  extended  knee  or  knees;  there  is  some- 
times ligamentous  laxity  of  a  number  of  joints.  The 
tibia  is  displaced  forward  on  the  condyles,  the  knee  is 
lax,  permitting  lateral  and  sliding  movements,  and  the 
patella  is  often  not  palpable  in  the  first  few  months;  it 
can  usually  be  felt  before  the  end  of  the  first  year,  but 
may  remain  small.  The  hyperextension  of  the  knee  is 
often  considerable,  and  it  may  be  impossible  to  bring 
the  leg  back  beyond  a  straight  line.  Popliteal  creases 
may  be  absent,  and  creases  may  be  present  in  front  of 
the  knee ;  the  femoral  condyles  are  abnormally  prominent 
in  the  popliteal  space.  Unless  the  legs  are  held  in  posi- 
tion and  gradually  flexed  by  strapping  the  child  to  a 
frame  bent  under  the  knees,  or  by  other  appliances,  the 
child  may  have  difficulty  in  walking  and  loose  knees. 
This  condition  is  a  rare  cause  of  knock-knee.  By  pre- 
venting extension  and  displacement  and  gradually  in- 
creasing the  flexion,  the  deformity  may  be  overcome; 
after  some  years,  during  which  a  jointed  supporting 
splint  may  be  worn,  the  knees  become  practically  normal. 


THE   KNEE  309 

Acquired  Deformities 

Acquired  genu  recurvatum  is  due  to  stretching  of  the 
posterior  ligament  of  the  knee-joint  when  motion  is  not 
sufficiently  checked  by  the  hamstring  muscles.  In  a  mild 
degree  it  is  often  seen  in  loose-jointed  and  delicate  chil- 
dren, and  it  is  common  in  inveterate  pes  equinus  and 
equino-varus ;  also  after  poliomyelitis  affecting  the  knee 
flexors,  especially  when  the  heel  cord  is  contracted  (Fig. 
31).  It  frequently  occurs  in  the  hypotonus  of  locomotor 
ataxia,  and  of  coxitis,  and  especially  in  the  latter  affec- 
tion if  traction  is  made  from  adhesive  strips  applied 
only  below  the  knee,  and  when  hyperextension  is  not 
prevented  by  a  steel  band  behind  the  knee.  In  the  para- 
lytic forms  of  genu  recurvatum,  and  in  that  complicating 
locomotor  ataxia,  apparatus  should  be  adjusted  to  pre- 
vent lateral  motion  and  to  keep  the  knee  slightly  flexed. 
The  bending  in  the  rachitic  form  is  usually  below  the 
knee-joint. 

Bursitis  About  the  Knee. — A  knowledge  of  the  location 
of  the  bursas  about  the  knee  is  necessary  in  order  to  dif- 
ferentiate knee  affections  and  treat  them  properly.  It 
should  be  remembered  that  a  bursa  may  be  irritated  by 
repeated  trauma,  and  is  liable  to  the  various  infections 
to  which  serous  membranes  are  subject. 

Prepatellar  bursitis,  or  housemaid's  knee,  is  usually  due 
to  working  in  the  kneeling  posture,  as  scrubwomen  are 
obliged  to  do.  It  appears  as  a  large,  rounded,  tense 
swelling  in  front  of  the  patella,  and  is  usually  filled  with 
a  gelatinous  fluid.  It  sometimes  suppurates.  The  ordi- 
nary form  may  be  treated  by  extirpation  of  the  sac,  or 


310      DEFOEMITIES    OF    LOWER   EXTREMITY 

by  incising  it  with  a  tenotone,  squeezing  out  the  jelly, 
making  multiple  scarifications  inside  the  sac  with  the 
tenotome  (Hoffman)  and  applying  firm  compression. 
When  pus  is  present  the  sac  should  be  opened,  irrigated, 
curetted,  or  dissected  out  and  dressed.  Prepatellar  bur- 
sitis should  not  be  confounded  with  tuberculosis  of  the 
patella. 

Pretibial  Bursitis. — The  pretibial  bursa  lies  between  the 
front  of  the  tibia  and  the  ligamentum  patella ;  when  dis- 
tended, it  projects  either  side  of  the  latter,  and  appears 
as  a  tense,  elastic,  or  fluctuating  swelling.  It  is  often 
affected  in  diseases  of  the  knee-joint,  but  it  is  not  in- 
frequently involved  without  affecting  the  knee.  If  filled 
with  pus,  it  should  be  evacuated,  disinfected,  and  scraped, 
otherwise  rest  and  strapping  are  usually  sufficient.  En- 
largement either  side  of  the  ligamentum  patellae  may  also 
be  caused  by  hypertrophied  synovial  fringes  below  the 
patella. 

Pretubercular  Bursitis. — There  is  in  some  individuals  a 
small  bursa  in  front  of  the  tibial  tubercle,  which  may 
become  inflamed  after  injury  or  otherwise,  and  give  rise 
to  a  small,  tense  swelling,  which  may  be  unilateral  or 
bilateral,  and  which  may  cause  pain,  especially  on  going 
upstairs.  This  condition  may  persist  for  a  long  time, 
and  give  rise  to  a  permanent  enlargement  of  the  tuber- 
cle. The  treatment  is  painting  with  iodin,  strapping, 
and  rest ;  stair  climbing  is  particularly  harmful.  Prompt 
relief  is  usually  afforded  by  such  treatment. 

Many  of  these  cases  in  adolescents  are  due  to  a  dias- 
tasis or  fracture  of  the  tubercular  epiphysis  (Osgood), 
a  narrow  tongue  of  bone  jutting  down  from  the  upper 


THE   KNEE  311 

tibial  epiphysis.  In  such  cases  pain,  swelling,  tenderness, 
and  disability  about  the  tibial  tubercle  comes  on  suddenly 
after  a  fall  or  blow.  A  lateral  skiagram  of  the  knee  will 
clearly  show  a  fracture  or  diastasis,  if  present.  Soreness 
and  disability  may  persist  for  some  time  unless  the  knee 
is  immobilized  for  three  or  four  weeks. 

The  bursae  under  the  hamstring  tendons  sometimes  be- 
come distended  or  inflamed,  and  may  require  tapping  and 
compression  or  more  vigorous  treatment. 

Accidents  to  the  Patella  and  its  Ligaments. — The  quadri- 
ceps tendon  may  be  torn  above  the  patella,  and  may 
require  suture. 

The  ligamentum  patellae  may  be  torn  from  its  tuber- 
cle, and  may  require  a  couple  of  stitches  to  reattach  it. 
Fractures  of  the  patella  are  common,  and,  unless  oper- 
ated, the  union  is  usually  by  ligament,  sometimes  with 
a  large  separation.  Function,  however,  is  often  good. 
If  one  is  a  master  of  asepsis,  it  is  good  practice  to  make 
a  transverse  incision  a  few  days  after  the  fracture,  turn 
out  the  clots,  and  unite  the  fibrous  tissue  at  either  side 
and  at  the  edges  of  the  patella  by  chromicized  gut.  A 
suture  through  the  bone  is  usually  unnecessary.  In  all 
of  these  injuries  the  leg  should  be  kept  in  full  extension 
by  a  back  splint  or  by  a  plaster-of-Paris  bandage. 

Slipping  Patella.- — The  patella,  after  once  being  dislo- 
cated, may  acquire  the  habit  of  slipping,  usually  to  the 
outer  side.  This  may  occur  in  knock-knee,  when  it  is 
often  sufficient  to  correct  the  deformity.  When  due  to 
other  causes,  the  ligamentum  patellae  may  be  exposed  by 
longitudinal  incision;  it  is  then  split  to  its  insertion  in 
the  tubercle  of  the  tibia:  the  half  of  the  tendon  toward 


312      DEFOEMITIES    OF    LOWEE    EXTEEMITY 

wliich  the  patella  slips  is  then  cut  off  at  its  insertion, 
pulled  under  the  half  which  still  remains  attached,  and 
sutured  to  the  periosteum  near  the  tubercle  on  the  oppo- 
site side  (Goldthwait).  This  pulls  the  patella  away  from 
the  side  toward  which  it  slips.  This  is  much  simpler 
than  Krogius's  operation  (Kocher),  and  seems  to  be 
equally  etfective. 

Tuberculosis  of  the  Patella. — The  patella  is  often  dis- 
eased in  tuberculosis  of  the  knee,  but  the  process  may 
also  begin  in  the  patella.  It  is  very  important  to  recog- 
nize this  early,  as  by  a  timely  scraping  operation  or, 
if  need  be,  by  excision  of  the  patella,  infection  of  the 
joint  may  be  avoided. 

The  symptoms  are  pain  in,  and  swelling  in  front  of, 
the  patella ;  this  swelling  may  contain  serum,  with  flocculi 
and  tuberculous  debris ;  the  anterior  surface  of  the  pa- 
tella may  be  felt  to  be  eroded,  or  erosion  may  be  revealed 
by  a  skiagram.  Extirpation  of  the  patella  does  not  in- 
terfere with  extension  of  the  knee  if  the  fascia  at  either 
side  is  sutured  together  in  the  median  line. 

Ankylosis  of  the  Patella. — The  patella  may  become  united 
to  the  articular  groove  of  the  femur  after  an  infection 
of  the  knee-joint.  If  it  has  become  ankylosed  while  the 
knee  was  flexed,  it  stops  extension,  and  its  adherence 
in  any  position  removes  all  voluntary  extension  and  flex- 
ion; any  motion  which  may  be  present  will  be  due  to 
laxity  of  the  ligamentum  patellae.  The  ankylosis  may 
be  fibrous,  when  it  may  permit  rocking,  or  bony,  when 
the  patella  is  absolutely  fixed.  When  the  patella  is  ad- 
herent there  is  usually,  but  not  always,  more  or  less 
adherence  between  the  tibia  and  femur.     If  the  knee- 


THE    KNEE  313 

joint  is  stiff  in  extension,  adhesion  of  the  patella  is  of 
no  importance.  If  the  knee  is  flexed,  it  may  be  straight- 
ened after  the  patella  is  loosened.  This  may  be  done 
by  inserting  an  osteotome  between  the  patella  and  femur, 
either  subcutaneously  or  through  an  open  incision.  There 
is  a  probability  of  readherence  after  correcting  the  flex- 
ion, and  if  motion  is  sought,  the  detachment  should  be 
effected  through  an  open  incision  at  the  side  of  the  pa- 
tella. Cargile  membrane  should  be  placed  between  the 
patella  and  the  femur  and  passive  motion  begun  in  ten 
days;  an  alternative  would  be  to  excise  the  patella,  and 
sew  the  fascia  together  in  the  median  line. 

Knock-knee  {in-hnee,  genu  valgum)  is  usually  a  rachitic 
deformity,  but  the  mild  grades  may  be  due  simply  to 
static  conditions  in  delicate  or  otherwise  normal  chil- 
dren. Knock-knee  may  be  due  to  other  causes,  and  often 
follows  tuberculosis  of  the  knee  and  infantile  paralysis. 
It  frequently  occurs  in  adolescents  who  stand  too  much 
or  carry  heavy  loads. 

The  deformity  may  be  principally  in  the  femoral  con- 
dyles, or  principally  at  the  upper  end  of  the  tibia,  or 
equally  in  both.  When  the  knee  is  flexed  the  knock-knee 
may  disappear.  The  knee  is  usually  somewhat  loose, 
from  stretching  of  the  internal  lateral  ligament ;  the  feet 
are  turned  out,  unless  instinctively  turned  forward  or 
in,  as  a  protection  to  the  weak  inner  side  of  the  knee 
and  foot.  Weak  feet  regularly  accompany  rachitic  and 
static  knock-knees,  and  aggravate  the  difficulty.  KJQOck- 
knee  is  usually  bilateral,  but  it  may  occur  on  one  side 
only,  or  be  paired  with  a  bow-leg  on  the  opposite  side. 
Anterior  curvature  of  the  tibia  is  often  found  with  knock- 

23 


314     DEFORMITIES    OF    LOWER    EXTREMITY 

knee  (Fig.  165) ;  it  is  possible  for  knock-knees  and  bow- 
legs to  exist  in  the  same  individual,  and  to  be  combined 


Fig.  165. — Rachitic  Bow-legs  and  Knock-knees.  The  children  show  the 
stigmata  of  rickets,  and  the  child  with  knock-knees  also  has  anterior 
bow-legs. 


with  anterior  curves  of  the  tibiae,  and  also  of  the  femora. 
With  knock-knees,  the  knees  rub  together  in  walking  and 
the  feet  are  not  properly  placed;  the  gait  is  stiff  and 


THE    KNEE  315 

awkward,  and  in  extreme  forms  walking  may  be  almost 
impossible.  For  purposes  of  record  the  bare  legs  of  the 
child  are  laid  on  a  large  piece  of  paper,  with  the  inner 
border  of  the  knees  in  contact,  and  a  pencil  tracing  of 
the  inner  border  of  the  legs  is  taken ;  this  gives  the  angle 
of  deviation,  and  the  separation  of  the  ankles.  By  com- 
paring this  record  with  others  taken  subsequently,  the 
progress  of  the  case  may  be  noted  with  exactness. 

Teeatment. — ^With  an  ankle  separation  of  two  inches 
or  less  in  young  children,  the  shoes  may  be  raised  one 
quarter  inch  on  the  inner  border,  which  inverts  the  foot, 
throws  the  weight  on  its  outer  border,  and  relieves  the 
inner  border  of  the  foot  and  the  inner  side  of  the  knee 
of  strain.  The  child  should  be  encouraged  to  toe  in. 
In  addition,  the  diet  should  be  regulated,  particularly 
if  the  child  is  rachitic,  and  it  should  be  kept  wholly  or 
in  part  off  its  feet.  Bicycle  and  pony  riding  are  per- 
missible. In  deformities  of  medium  grade  in  children 
under  four,  the  Thomas  knock-knee  braces,  when  worn 
for  a  year  or  more,  are  often  effective  (Fig.  166). 
Braces  which  are  jointed  at  the  knee  are  ineffectual. 
In  the  severe  cases  the  legs  must  be  straightened  by 
an  operation;  in  children  one  may  choose  between  os- 
teoclasis and  osteotomy ;  both  give  excellent  results.  For 
subcutaneous  osteotomy  the  patient  is  anesthetized,  and 
placed  on  the  side  with  the  leg  to  be  operated  upper- 
most and  a  sand  bag  under  the  inner  side  of  the  femur. 
An  assistant  steadies  the  flexed  leg,  while  the  operator 
grasps  the  femur  between  the  left  thumb  and  forefinger 
above  the  condyles  and  pushes  the  sharp  osteotome,  its 
edge  parallel  with  the  shaft  and  corner  first,  through  the 


316     DEFORMITIES   OP   LOWER   EXTREMITY 

skin,  and  down  to  the  bone  a  finger's  breadth  above  the 
external  condyle  (Fig.  167).  After  cuttiag  the  perios- 
teum, the  osteotome  is  rotated  ninety  degrees  to  bring 
the  edge  across  the  axis  of  the  shaft,  and  two  thirds  or 
three  quarters  of  the  shaft  is  divided  by  blows  of  the 
mallet,  the  chisel  being  directed  toward  the  center  of 


Fig.  166. — Thomas's  Knock-knee  Splints  with  Pelvic 
Half-bands  Added. 

the  shaft;  one  should  be  careful  to  divide  the  cortex  for 
more  than  half  the  circumference.  The  fracture  is  then 
completed  by  hand  or  over  the  wooden  wedge,  the  de- 


THE    KNEE  317 

formity  somewhat  overcorrected,  one  suture  inserted, 
and  the  leg  placed  in  a  long  spica  from  waist  to  toes. 
If  the  operation  is  upon  both  sides  the  spica  is  double, 


Fig.  167. — Subcutaneous  Osteotomy  Above  the  Condyles  for  Knock- 
knee.  The  figure  shows  the  proper  posture  of  the  hands  for  driving  the 
osteotome  through  the  bone;  the  osteotome  is  not  yet  turned  at  right 
angles  to  the  shaft  of  the  femur,  as  it  should  be  before  the  bone  is  attacked. 
Note  size  and  shape  of  osteotome  (compare  Fig.  199),  and  potato-masher 
used  as  a  mallet. 

and  for  convenience  the  legs  should  be  somewhat  ab- 
ducted; the  spica  may  be  reenforced  by  a  bar  or  other 
support  below  the  knees.  The  final  appearance  in  the 
splints  should  be  one  of  slight  bow-legs.  This  operation 
from  the  outer  side  is  known  as  MacCormac's ;  it  is  some- 


318      DEFORMITIES    OF    LOWER    EXTREMITY 

what  preferable  to  Macewen's  operation  from  the  inner 
side.  Either  operation  may  be  done  through  an  open 
cut,  if  preferred.  In  cases  where  the  deformity  is  mod- 
erate or  where  the  bending  is  largely  below  the  knee, 
the  operation  may  be  done  on  the  tibia  below  the  tuber- 
osities ;  in  such  cases  the  correction  is  more  perfect,  and 
the  plaster  splint  reaches  only  from  the  toes  to  the  groin. 
In  adolescents  and  adults  osteotomy  is  the  operation  of 
choice ;  in  children,  however,  with  a  good  osteoclast  such 
as  Grattan's,  osteoclasis  is  the  quicker  and  simpler  oper- 
ation, and  is  just  as  effective.  Some  skill  is  necessary 
to  break  the  bone  near  the  joint  in  small  legs,  but  with 
practice,  and  by  bringing  the  plunger  of  the  osteoclast 
nearer  to  the  bar  next  to  the  joint,  clean  fractures  may 
be  made  very  near  the  condyles  or  tuberosities.  One 
may  break  above  or  below  (Blanchard)  the  knees,  ac- 
cording to  the  deformity.  In  osteoclasis  the  screw  must 
be  worked  and  released  very  quickly,  as  the  tissues  are 
not  harmed  by  extreme  pressure  if  momentary,  but  easily 
slough  under  prolonged  pressure.  The  overcorrection 
and  the  splinting  are  the  same  as  after  osteotomy. 

For  genu  varum  see  Bow-legs. 

Paralytic  and  Spastic  Deformities  of  the  Knee. — After  polio- 
myelitis with  partial  or  complete  paralysis  of  the  flexors 
and  quadriceps,  if  the  patient  walks  by  locking  the  knee 
back  mechanically,  or  if  the  knee  is  forced  back  by  a 
tight  heel-cord,  a  grave  recurvature  may  develop  from 
stretching  of  the  posterior  ligament.  If  the  knee  flexors 
are  active,  and  particularly  if  the  patient  has  been  for 
a  long  time  confined  to  the  sitting  posture,  there  may 
be  permanent  flexion  of  the  knee  from  adaptive  shorten- 


THE  KNEE  319 

ing.  In  many  severe  cases  the  flexion  will  be  combined 
with  subluxation  of  the  tibia  backward,  knock-knee,  and 
outward  rotation  of  the  leg — the  same  deformities  that 
develop  in  tuberculous  gonitis  and  other  chronic  inflam- 
mations. In  many  of  the  paralytic  cases  the  biceps  is 
active,  and  may  help  to  produce  the  knock-knee  and  out- 
ward rotation  by  its  contraction.  The  subluxation  is  due 
to  the  pull  of  the  hamstrings  in  the  flexed  posture.  In 
spastic  palsy  there  is  also  a  strong  tendency  to  knee 
flexion,  which,  however,  may  be  temporarily  overcome 
by  stretching. 

In  the  adaptive  flexions  the  knee  may  be  straightened 
under  anesthesia,  with  tenotomy  of  the  hamstrings  when 
necessary.  The  biceps  most  often  needs  division,  and  the 
insertion  of  the  ilio-tibial  band  which  lies  in  front  of  it. 
The  biceps  should  be  divided  through  an  open  cut  or 
hooked  up  through  a  small  incision  in  order  not  to  injure 
the  external  popliteal  nerve  which  lies  directly  internal 
to  it.  The  internal  popliteal  nerve  may  also  stand  out 
as  a  tense  cord  near  the  middle  of  the  popliteal  space 
when  the  contracted  knee  is  stretched.  The  posterior 
part  of  the  lateral  ligaments  may  present  a  strong  obsta- 
cle to  correction,  and  may  be  divided  subcutaneously, 
taking  care  not  to  injure  the  external  popliteal  nerve. 
After  full  correction  the  leg  is  put  up  in  plaster-of-Paris 
from  the  toes  to  the  groin  for  from  four  to  six  weeks, 
during  which  time  a  two-barred,  straight  supporting 
splint  is  prepared.  This  splint  may  be  either  without 
a  joint  at  the  knee,  so  that  the  knee  is  held  continuously 
in  extension,  or  it  may  have  a  snap  joint,  making  it  stiff 
in  extension  when  walking,  and  allowing  it  to  bend  by 


320     DEFOEMITIES    OF   LOWER    EXTREMITY 

touching  a  release  when  the  patient  desires  to  sit.  In 
many  cases,  however,  even  when  there  is  little  power 
in  the  quadriceps,  a  brace  with  a  free  joint,  giving  lat- 
eral support  and  to  prevent  hyperextension,  is  sufficient. 

If  the  sartorius  and  hamstrings  are  active,  they  may 
be  transplanted  into  the  paralyzed  quadriceps  tendon; 
or  an  arthrodesis  may  be  done  to  produce  ankylosis. 
Neither  of  these  operations  is  indicated  if  the  patient 
is  satisfied  to  wear  a  proper  supporting  apparatus.  When 
there  is  a  flail-joint  without  antero-posterior  or  lateral 
stability,  arthrodesis  is  the  best  operation,  though  it  is 
not  difficult  to  hold  such  a  knee  in  proper  posture  for 
locomotion  by  a  removable  splint  or  brace. 

Spastic  contracture,  if  severe,  should  be  relieved  by 
tenotomy  of  the  hamstrings  and  correction,  since  the  de- 
formity recurs  if  simple  stretching  is  employed,  and 
tenotomy  exercises  a  favorable  effect  upon  the  spasm. 

Acute  synovitis  is  often  due  to  a  blow,  fall,  twist,  or 
strain  of  the  knee.  It  is  characterized  by  pain,  tender- 
ness, and  effusion,  with  varying  amounts  of  stiffness  and 
local  heat.  The  effusion  may  be  detected  by  the  fluc- 
tuation above  and  below  the  patella,  and  by  the  ballotte- 
ment  of  the  latter.  The  principal  dangers  are  aggra- 
vation of  the  condition  by  traumatic  insults  and  the  in- 
fection of  the  sjmovial  cavity  by  pus  or  other  pathogenic 
microbes,  which  happens  oftener  if  the  knee  is  used. 
Acute  synovitis  may  also  occur  from  the  pinching  of 
an  hypertrophied  synovial  villus,  or  from  the  impaction 
of  a  floating  body  or  a  displaced  semilunar  cartilage. 
Synovitis  or  a  passive  hydrops  may  be  secondary  to 
many  pathological  conditions. 


THE   KNEE 


321 


The  joint  should  be  strapped  or  bandaged  and  put 
at  rest  in  a  fixation  splint.  If  the  process  is  mild 
the  patient  may  go 
about  on  crutches;  if 
severe,  he  should  be 
put  to  bed,  and  mild 
traction  added.  With 
adequate  protection 
a  simple  synovitis 
should  recover  in 
three  to  six  weeks. 
Obstinate  cases  often 
prove  to  be  infected 
with  pus,  gonorrheal 
or  other  germs.  As- 
piration of  the  fluid 
under  full  asepsis  may 
prove  useful  for  diag- 
nosis. 

Intermittent  hydrops 
is  a  rare  condition  of 
unknown  causation,  in 
which  effusion  into 
the  joint  occurs  at 
regular  intervals  of 
a  few  days  to  a  few 
weeks,  each  attack 
passing  off  in  a  few 
days. 

Chronic  hydrops  of  one  or  both  knees  may  persist, 
sometimes    with    remissions,    many    years.      Common 


Fig.  168. — Chronic  Hydrops  of  Both 
Knees;  Duration,  Ten  Years  with 
Varying  Intensity;  Ankles  Have  Also 
BEEN  Affected;  Man  of  Twenty- 
three. 


322     DEFORMITIES    OF    LOWER    EXTREMITY 

causes  are  tuberculosis  and  syphilis,  but  some  cases 
are  difficult  to  account  for  (Fig.  168). 

Gonitis  TuberculossL  (White  Swelling). — The  knee  is  the 
largest  joint  in  the  body,  and  one  of  the  most  accessible. 
After  the  spine  and  hip,  it  is  the  most  frequent  articular 
seat  of  tuberculous  infection.  Its  large  size  and  exposed 
position  make  it  easy  to  examine,  and  its  extended  lever- 
age makes  it  readily  splinted  and  controlled.  Tubercu- 
lous gonitis  is  commonest  in  children,  but  may  occur  at 
any  age. 

Pathological  Anatomy. — Infection  comes  by  way  of 
the  blood,  and  may  be  synovial  or  osteal;  the  latter  is 
the  more  common.  In  osteal  infection  there  is  a  focus 
(Fig.  14),  wedge-shaped  infarct,  or  diffuse  infiltration, 
which  leads  to  flabby  granulations,  causing  bone  soften- 
ing in  the  neighborhood,  and  which  may  progress  to  case- 
ation, the  formation  of  small  sequestra  or  ichor  cysts 
(cold  abscesses),  or  may  cicatrize  at  any  stage.  The 
surrounding  bone  undergoes  expansion,  and  the  neigh- 
boring epiphyseal  cartilage  is  stimulated,  causing  in- 
creased growth  in  length.  As  the  granulations  or  fluids 
work  toward  the  articular  cartilage,  the  latter  becomes 
detached  or  perforated,  and  the  synovial  membrane  be- 
comes secondarily  infected;  the  changes  and  symptoms 
of  chronic  tuberculous  synovitis  are  thus  added  to  those 
of  tuberculous  epiphysitis.  In  a  considerable  number  of 
cases  the  synovial  membrane  is  primarily  affected,  and 
undergoes  extensive  thickening  and  pulpy  degeneration, 
with  more  or  less  effusion  of  serum  and  deposit  of  fibrin. 
Such  a  condition  may  last  for  years  with  mild  symptoms, 
and  without  affecting  cartilage  or  bone.     Cartilage  is 


THE   KNEE 


323 


very  resistant  to  infection;  it  derives  its  nutrition  from 
underlying  bone,  and  may  atrophy  or  become  detached 
if  this  is  diseased.  So  long  as  it  rests  upon  sound  bone 
it  presents  a  formidable  barrier  to  the  spread  of  dis- 
ease from  the  interior  of  the  joint  to  the  bone  (Nathan). 
Symptoms. — The  invasion  is  usually  insidious  and 
progress  slow.    Lameness  and  swelling  are  first  noticed; 


Fig.  169. — Tuberculous  Osteitis  op  the  Right  Knee,  op  Two  Years' 
Duration  in  a  Girl  op  Five  ;  No  Mechanical  Treatment. 


pain  may  be  absent  for  some  time.  The  swelling  is  due  to 
joint  effusion  and  bony  and  synovial  thickening,  and  tends 


324     DEFORMITIES    OF   LOWER   EXTREMITY 

to  obliterate  the  landmarks  of  the  knee  in  front  and  at  the 
sides;  it  is  often  described  as  a  fusiform  swelling  (Fig. 
169).  The  skin  is  usually  pale  and  thickened.  The  knee 
is  invariably  somewhat  flexed  and  motion  is  limited;  as 
the  disease  progresses,  flexion  and  stiffness  increase  and 
knock-knee  and  eversion  of  the  leg  are  usually  added; 
the  process  may  end  in  ankylosis,  and  the  patella  may 
also  become  adherent.  Sinuses  often  form,  leading  into 
the  joint  or  into  the  bone  focus.  When  the  knee  is  ex- 
amined it  is  found  to  be  enlarged  in  all  its  measurements, 
and  if  the  disease  is  osteal  the  condyles  are  thickened 
and  enlarged.  It  is,  however,  sometimes  impossible  to 
decide  without  a  skiagram  whether  there  is  bony  thick- 
ening or  not  on  account  of  the  thickening  of  the  synovial 
membrane  and  overlying  parts.  There  may  or  may  not 
be  effusion  into  the  joint,  with  floating  of  the  patella,  at 
the  time  of  the  examination.  One  or  more  tender  areas 
may  usually  be  found  in  the  femoral  condyles,  or  more 
rarely  in  the  tibial  tuberosities.  The  tuberculous  process 
in  the  epiphysis  stimulates  the  bones  to  increased  growth 
in  length,  and  the  affected  leg  is  regularly  from  one  quar- 
ter to  one  inch  longer  during  the  active  stage  of  the  dis- 
ease. This  fact  is  of  considerable  diagnostic  importance. 
The  increased  length  is  usually  mostly  in  the  femur. 
While  increased  growth  is  taking  place  near  the  knee, 
other  parts  of  the  limb  are  retarded  in  growth,  and  a 
time  is  usually  reached  when  the  measurements  of  the 
two  limbs  are  equal.  When  this  is  the  case,  however, 
the  femur  is  usually  longer  and  the  tibia  shorter  than  the 
corresponding  bones  of  the  well  side.  After  many  years, 
if  the  disease  has  been  severe,  atrophy  preponderates, 


THE-  KNEE  325 

and  the  final  result  may  be  a  limb  shorter  than  its  fellow 
by  one  or  more  inches. 

Chronic  tuberculous  synovitis  occurs  oftener  in  ado- 
lescents and  young  adults;  its  progress  is  slower,  and 
there  is  usually  less  pain,  stitfness,  and  disability.  The 
swelling,  which  is  partly  due  to  effusion  and  partly  to 
thickening  of  the  synovial  membrane  and  overlying  tis- 
sues, may  be  very  great.  More  or  less  soft  crepitus 
may  be  present.  The  underlying  bone  may  seem  to  be 
enlarged  when  it  is  not. 

The  PKOGNosis  for  cases  seen  early  and  carefully 
treated  is  good;  the  majority  recover  with  a  stiif  knee, 
a  good  posture,  and  a  serviceable  leg.  Many  die  from 
septic  and  tuberculous  accidents,  if  neglected,  and  many 
others,  after  years  of  suffering,  recover  with  disabling 
deformity. 

Diagnosis. — Pus  joints  sho,uld  be  carefully  distin- 
guished, especially  in  young  babies;  they  have  a  more 
rapid  invasion,  and  are  accompanied  by  fever  and  local 
heat,  and  other  acute  symptoms  both  local  and  constitu- 
tional. Syphilitic,  gonorrheal,  and  other  infections,  and 
effusions  of  blood  must  also  be  differentiated. 

Arthritis  deformans  and  osteoarthritis  are  usually 
polyarticular,  and  never  suppurate;  they  are  rare  in 
children. 

Teeatment. — Tonic  and  fresh-air  treatment  is  indi- 
cated, and  the  diseased  joint  should  be  relieved  of  mo- 
tion and  weight  by  an  immobilizing  splint  and  crutches. 
Splints,  whether  of  plaster  or  other  material,  should 
include  the  foot  and  reach  to  the  groin.  Many  splints 
are  made  far  too  short.    An  excellent  immobilizing  ap- 


326     DEFORMITIES   OF   LOWER   EXTREMITY 

paratus,  which  at  the  same  time  suspends  the  limb  and 
thus  takes  off  all  weight,  is  the  Thomas  splint,  which  is 


Fig.  170. — Thomas's  Splint  for  Suspending  and  Immobilizing  the  Knee. 
When  the  splint  is  buckled  to  adhesive  plaster  placed  below  the  knee, 
shoulder  straps  are  unnecessary,  and  a  certain  amount  of  traction  may  be 
exerted. 


two  and  a  half  to  three  inches  longer  than  the  limb,  and 
takes  the  weight  on  a  padded  ring  (Fig.  170).  It  is 
worn  with  two-and-a-half-  to  three-inch  cork  sole  in  the 


THE    KNEE  327 

shoe  of  the  well  side.  Immobilization  and  protection 
must  usually  be  continued  for  several  years  before  cure 
is  accomplished. 

There  is  a  better  chance  at  the  knee  than  in  most 
joints  to  localize  the  focus  by  a  skiagram  while  it  is 
still  extra-articular,  and  excise  it.  This  can  occasionally 
be  done,  and  the  joint  saved  from  serious  damage.    After 


Fig.  171.  Fig.  172. 

Figs.  171  and  172.^ — Results  after   Early   Excision  of  the  Knee. 
The  patient  at  the  right  has  ten  inches  shortening. 

the  joint  is  infected,  however,  the  operations  of  erasion 
and  excision  are  unsatisfactory  in  children  on  account 
of  the  difficulty  in  removing  all  diseased  tissue,  the  seri- 


328     DEFORMITIES    OF   LOWER   EXTREMITY 


ous   interference   with  growth,   which  may  amount   to 
eight  or  ten  inches,  or  even  more,  and  to  the  liability 

to  flexion  and  other 
deformities  years 
after  the  operation 
(Figs.  171,  172,  and 
173).  These  objec- 
tions to  the  opera- 
tion are  so  serious 
that  it  should  not 
be  done  in  children 
under  fifteen  except 
as  a  life-saving 
measure,  when  it  is 
often  preferable  to 
amputation.  In 
adults  it  may  be 
much  more  freely 
employed,  and  is 
often  the  treatment 
of  choice,  even  in 
fairly  early  cases. 

The  synovial  cases 
may  be  benefited  by 
arthrotomy,  to  re- 
lease fluid  and  cut 
out  synovial  fringes,  but  without  scraping ;  in  inveterate 
cases  the  entire  hypertrophied  synovial  membrane  may 
be  removed  by  an  arthrectomy.  The  knee  should  be 
carefully  splinted  for  a  year  or  more  after  operations. 
Bier's  congestion  treatment  may  be  used  in  addition  to 


Fig.  173. — Ankylosis  with  Right  Angle 
Deformity  after  Excision  at  Five 
Years  of  Age  ;  the  Knee  was  Splinted 
FOR  Seven  Months  after  the  Opera- 
tion; THE  Girl  is  now  Twelve. 


THE   KNEE  329 

mechanical  protection  and  rest.  The  results  of  such 
treatment,  however,  in  tuberculous  disease  do  not  appear 
to  be  markedly  better  than  from  orthopedic  treatment 

alone. 

Treatment  of  Deformities 

Flexion  deformity  occurring  during  the  active  stage 
of  the  disease  may  be  overcome  by  traction  in  bed  or  by 
gradually  straightening  the  splint.  Care  should  be  taken 
to  pull  the  head  of  the  tibia  forward.  If  seen  early,  seri- 
ous deformities  will  be  prevented  by  proper  splinting. 
Flexion  in  cured  cases  may  be  overcome  by  stretching 
fibrous  adhesions  under  anesthesia,  when  Whitman's  pos- 
ture, the  patient  procumbent,  is  often  advantageous.  In 
other  cases  the  Bradford-Goldthwait  corrector,  which 
slides  the  tibia  forward  on  the  femur  as  extension  is 
made,  gives  excellent  results.  If  the  patella  is  adherent 
it  may  be  chiseled  free,  subcutaneously  or  through  an 
open  incision. 

Flexion  and  knock-knee  with  bony  ankylosis,  if  the 
deformity  is  not  too  great,  may  be  readily  corrected  by 
an  osteotomy  above  the  knee.  Very  severe  deformities 
may  require  osteotomies  both  above  and  below,  or  a  cu- 
neiform excision  of  the  ankylosed  joint.  If  flexion  is 
extreme,  great  care  should  be  used  to  avoid  splinters  in 
the  popliteal  space,  and  to  avoid  strangling  the  popliteal 
vessels  by  too  brusque  a  correction.  In  case  of  doubt 
the  correction  may  be  effected  in  steps.  When  there  is 
much  cicatricial  tissue  in  the  popliteal  space,  an  anterior 
longitudinal  incision  should  be  employed.  Recently  it  has 
been  proposed  to  attempt  to  mobilize  the  ankylosed  knee 
by  opening  the  joint  and  interposing  a  fat  and  fascia  flap 

23 


330      DEFORMITIES    OF    LOWER    EXTREMITY 

between  the  bone  surfaces    (arthroplasty) ;  the  results 
have  not  been  brilliant. 

Othee  Affections  of  the  Knee 

Gonorrheal  infection  of  the  knee  may  be  mild  or  severe ; 
the  periarticular  tissues  are  often  much  involved,  and 
there  is  a  great  deal  of  swelling,  and  sometimes  effusion. 
The  disease  may  be  monarticular  or  polyarticular,  but 
does  not,  as  a  rule,  involve  many  joints.  Splinting  is 
demanded  in  the  acute  stage,  and  symptomatic  treatment, 
with  special  attention  to  the  original  focus.  Gonorrheal 
and  other  specific  infections  are  often  followed  by  stiff- 
ness. Bier's  congestion  treatment  may  give  striking  re- 
sults in  the  relief  of  pain. 

Syphilis  of  the  knee  may  be  manifested  as  a  chronic 
hydrops  which  may  affect  both  knees,  or  as  a  gummatous 
involvement  of  the  bone  or  synovial  membrane.  Anti- 
syphilitic  medication  with  very  little  local  treatment  will 
sometimes  act  almost  like  magic. 

Pus  infections  of  the  knee  may  be  synovial  or  osteal  from 
an  osteomyelitis  of  the  neighboring  bone  ends.  The 
symptoms  are  often  acute  and  urgent.  If  pus  in  the 
joint  is  found  by  puncture,  the  joint  should  be  opened, 
irrigated,  and  drained.  If  an  osteomyelitis  is  found,  and 
confirmed  by  the  skiagraph,  the  diseased  focus  should  be 
removed  by  an  extra-articular  operation  as  early  as  pos- 
sible in  order  to  prevent  joint  involvement. 

The  knee  may  become  infected  or  inflamed,  often  with 
other  joints,  in  the  course  of  almost  any  acute  infectious 
disease,  and  the  treatment  should  be  joint  rest,  and  atten- 
tion to  the  underlying  cause.    During  convalescence  the 


THE    KNEE 


331 


articulation  is  slowly  led  back  to  use  by  apparatus, 
crutches,  and  devices,  to  permit  partial  or  limited  use, 
and  by  measures  to  promote  joint  nutrition.  Deformities 
should  be  prevented,  and 
if  present,  treated  much 
as  are  those  following- 
tuberculosis. 

Hemarthros.  See  He- 
mophilia, page  18. 

Charcot's  Knee  (Fig. 
174).  See  Trophic  joints, 
page  70. 

Arthritis  deformans  is 
usually  polyarticular, 
with  involvement  of  many 
joints,  both  small  and 
large.  Particular  atten- 
tion should  be  given  to 
the  underlying  condition 
as  laid  down  in  the  gen- 
eral section,  and  to  the 
prevention  of  deformity 
by  proper  splinting.  For- 
midable as  this  affection 
undoubtedly  is,  all  cases 
are  not  of  the  severe  type, 
and  even  in  these  very 
much  can  be  effected  by 
rational  management. 

Osteoarthritis  is  particularly  prone  to  involve  one  or 
both  knees.    It  may  develop  after  an  injury  or  after  the 


Fig.  174. — Right  Charcot  Knee  in 
A  Man  op  Thirty-eight.  Knee 
symptoms  appeared  two  years  be- 
fore ataxia  was  noticed. 


332     DEFOEMITIES    OF    LOWER    EXTREMITY 

strains  imposed  by  an  old  deformity,  such  as  knock-knee; 
many  cases  are  due  to  senile  changes ;  often  the  cause  is 
unknown.  The  synovial  membrane  is  often  thickened, 
and  may  be  tender  in  certain  areas ;  there  is  often  creak- 
ing of  the  joints  on  motion,  easily  felt  and  sometimes 
heard ;  motion  is  often  restricted,  and  there  may  be  points 
of  tenderness  located  about  the  periphery  of  the  joint; 
at  these  points  bony  enlargement  may  sometimes  be  made 
out  by  palpation,  and  frequently  by  skiagraphy ;  the  knee 
may  become  flexed  or  otherwise  deformed.  The  patient 
complains  of  j)am,  weakness,  stiffness,  and  difficulty  in 
walking  and  going  upstairs.  It  should  be  said  that  large 
numbers  of  knee-joints  creak  more  or  less  after  the  age 
of  forty,  and  even  before,  in  persons  who  are  not  con- 
scious of  any  disability ;  creaking,  unless  severe  or  asso- 
ciated with  other  symptoms,  is  not  necessarily  indicative 
of  present  or  impending  knee  trouble.  Many  cases  of 
osteoarthritis  of  the  knee  are  comparatively  mild  and 
self -limited,  or  recede  under  such  simple  treatment  as 
strapping,  bandaging,  the  high-frequency  current,  vibra- 
tion, a  knee  cap  or  lacing,  restriction  of  activity,  and 
regulation  of  diet.  For  the  severe  cases  with  deformity, 
protective  appliances  are  often  of  great  value;  opera- 
tions are  occasionally  required.  One  should  not  mistake 
the  knee  pain  often  present  in  osteoarthritis  of  the  hip 
and  other  hip  affections  for  a  knee  symptom.  In  knee 
pain,  the  hip  as  well  as  the  knee  should  always  be  exam- 
ined. 

Villous  arthritis  of  the  knee  may  be  a  primary  affection 
produced  according  to  Schiiller  by  a  specific  microbe,  or 
it  may  be  secondary  to  osteoarthritis  and  various  other 


THE    KNEE  333 

knee  affections.  Villous  arthritis  is  characterized  by  hy- 
pertrophied  villi  and  folds  of  synovial  membrane,  which 
sometimes  cause  swelling,  and  may  be  palpated  either 
side  of  the  patellar  tendon  or  in  the  upper  comers  of  the 
synovial  sac.  If  one  of  these  tabs  is  caught  in  the  joint 
and  pinched,  sudden  disability,  pain,  swelling,  and  effu- 
sion may  follow.  These  usually  pass  off  in  a  few  days 
after  rest,  strapping,  and  bandaging,  but  are  liable  to 
recur.  The  hypertrophy  is  sometimes  extreme,  and  the 
disability  very  serious.  In  some  cases  fat  is  deposited 
in  and  about  the  villi,  which  atrophy,  leaving  a  lipoma 
arborescens  free  in  or  adjacent  to  the  joint  sac;  lipomata 
may  also  develop  after  an  injury.  If  the  pain  and  dis- 
ability are  serious  and  refractory  to  mild  measures,  the 
joint  may  be  aseptically  opened  and  the  hypertrophied 
villi  or  fatty  tumors  removed.  If  oozing  is  copious  the 
joint  may  be  washed  out  with  hot  saline  solution.  This 
operation,  while  undoubtedly  successful  under  proper 
conditions,  should  not  be  lightly  undertaken,  nor  at  all 
unless  the  symptoms  are  of  sufficient  importance  to  de- 
mand it. 

Floating  Bodies  {Joint  Mice). — Hard  or  cartilaginous 
bodies  are  sometimes  broken  off  from  the  edge  of  the 
joint  or  formed  from  villi  or  other  tissues,  and  float  free 
or  attached  by  a  pedicle,  changing  their  position  with  the 
movements  of  the  joint.  They  may  be  felt  at  times  as 
a  smooth,  hard  body  or  bodies  slipping  under  the  finger 
in  certain  definite  localities.  Unless  pinched  by  the  joint 
they  may  give  rise  to  no  symptoms,  but  when  caught  be- 
tween the  joint  surfaces  they  may  cause  a  sudden  locking 
of  the  joint,  pain,  and  disability,  often  followed  by  swell- 


334      DEFOEMITIES    OF    LOWER    EXTREMITY 

ing  and  effusion.  These  accidents  recur  at  intervals. 
Such  floating  bodies  require  removal,  which  is  often  eas- 
ily effected  through  a  small  opening.  The  operation 
should  not  begin  until  the  floating  body  is  felt  under  the 
skin,  as  otherwise  it  is  sometimes  very  difficult  to  find  it 
even  through  a  large  incision. 

Displacement  of  the  Semilunar  Cartilage  {Internal  De- 
rangement of  the  Knee). — A  semilunar  cartilage,  usually 
the  internal,  may  become  bruised,  torn,  or  displaced  from 
a  misstep  or  sudden  twist  of  the  knee.  There  is  sudden 
acute  pain,  with  locking  of  the  knee,  which  may  usually 
be  worked  loose;  this  is  followed  by  pain,  swelling  (effu- 
sion), limitation  of  motion  and  disability,  and  there  is 
tenderness  over  the  cartilage;  sometimes  a  projecting 
edge  of  cartilage  may  be  felt  or  an  increased  joint  inter- 
val ;  more  often  both  are  absent.  Atrophy,  especially  of 
the  quadriceps,  is  rapid  and  severe.  Sometimes  the  dis- 
placement may  be  overcome  by  flexing  and  extending  the 
knee  under  anesthesia  while  pressure  is  made  over  the 
cartilage.  This  should  be  followed  by  a  compress  and 
fixation  for  two  weeks.  Many  cases,  however,  are  refrac- 
tory, and  become  chronic;  the  luxation  may  or  may  not 
be  repeated  at  intervals,  and  there  is  pain,  disability, 
tenderness,  and  atrophy.  Some  cases  improve  under 
strapping,  bandaging,  and  the  use  of  a  knee  cap  or 
lacing,  others  under  a  jointed  supporting  splint  (Shaf- 
fer). In  a  considerable  number  of  cases  all  these 
measures  fail,  and  the  injured  or  displaced  cartilage 
may  require  removal.  It  is  usually  sufficient  to  re- 
move a  triangular  piece  through  a  longitudinal  inci- 
sion.    The  absence  of  a  part  or  the  whole  of  a  semi- 


THE    LOWER    LEG  335 

lunar   cartilage   does   not   interfere   with   good   use   of 
the  knee. 

Floating  bodies,  semilunar  injuries,  or  displacement, 
and  certain  cases  of  enlarged  villi  may  give  rise  to  similar 
symptoms,  and  require  careful  study  for  diiferentiation. 

Defokmities  of  the  Lower  Leg  (Knee  to  Ankle) 
Congenital  Defects  of  the  Tibia  and  Fibula 

The  tibia  or  fibula  may  be  defective  or  entirely  ab- 
sent; defects  of  the  fibula  are  much  more  frequent  than 
those  of  the  tibia.  If  the  defect  is  partial  the  lower  ex- 
tremity of  the  bone  is  usually  the  part  which  remains 
undeveloped.  These  defects  are  regularly  associated  with 
characteristic  changes  in  the  companion  bone  and  in  the 
foot. 

With  absent  fibula,  the  tibia  is  short,  thick,  and  bent 
at  the  junction  of  the  middle  and  lower  thirds ;  this  bend- 
ing may  be  very  acute,  and  there  is  usually  a  furrow  or 
dimple  over  this  angle.  This  deformity  has  been  called 
intrauterine  fracture,  which  it  usually  is  not.  Muscles 
and  tarsal  bones  may  be  absent  or  anomalous,  especially 
on  the  fibular  side.  Toes  and  metatarsal  bones  are  fre- 
quently absent,  and  when  this  is  the  case  they  fall  away 
in  order  from  the  fibular  side  of  the  foot;  if  one  toe  is 
absent,  it  is  the  fifth;  if  two,  the  fifth  and  fourth,  and 
so  on  (Fig.  175).  The  outer  malleolus  being  absent,  the 
foot  is  drawn  into  the  equino-valgus  posture,  which  is 
increased  if  the  child  walks.  The  whole  limb  is  short, 
and  the  shortening  may  be  partly  in  the  femur;  this 
shortening    increases    with    age,    and    may    ultimately 


336     DEFORMITIES    OF    LOWER    EXTREMITY 


amoTint  to  five  or  six  inclies  or  more.     Tlie  knee  raay 
be  imperfectly  formed,   and  is  often   somewhat  flexed 

but   is   usually   stable;   there 
is  no  paralysis. 

The  indication  for  treat- 
ment is  to  correct  the  malpo- 
sition of  the  foot.  This  may 
be  done  in  infants  by  tenot- 
omy of  the  heel  cord,  manipu- 
lation, and  retention  in  plas- 
ter, but  correction  is  often 
difficult  and  relapse  almost 
certain,  on  account  of  ab- 
sence of  the  external  malleo- 
lus. In  older  children,  the 
ankle-joint  may  be  opened  by 
Kocher's  fish-hook  incision 
and  an  arthrodesis  of  the 
ankle  performed.  The  writer 
has  done  this  once  with  fair 
success. 

In  absence  of  the  tibia,  a 
very  rare  condition,  the  fibula 
is  large,  short,  and  bent,  and 
the  foot  is  in  equino-varus. 
The  knee-joint  is  unstable,  as  the  fibula  does  not  take  the 
weight  and  moves  in  every  direction.  One  or  more  toes 
and  metatarsals  are  often  wanting  on  the  inner  side  of 
the  foot.  On  account  of  its  instability  the  leg  is  prac- 
tically useless.  The  fibula  may  be  implanted  between 
the  condyles,  and  united  to  the  astragalus  or  os  calcis. 


Fig.  175.  —  Congenital  Ab- 
sence OF  Left  Fibula  and 
Fourth  and  Fifth  Toes. 


THE   LOWEE   LEG 


337 


Acquired  Deformities  of  the  Tibia  and  Fibula 

In  bow-legs  and  genu  varum,  or  out-knee,  the  opposite 
deformity  to  knock-knee,  the  knee  is  carried  ontward  by 
bending  of  the  femur  or  tibia  or  both,  or  by  a  deformity 
of  the  condyles  or  tibial  tuberosities.  This  deformity 
may  be  caused  by  injuries  with  outward  displacement  of 


Fig.  176. — Moderate  Bow-legs  in  Child  of  Two,  with  Knight's  Splint. 
A  pencil  tracing  of  the  deformity  is  shown  at  the  upper  left-hand  corner. 

the  knee,  or  followed  by  a  gradual  yielding  due  to  insuf- 
ficient stability;  it  has  been  observed  after  excision  of 
the  knee  in.  children.  There  is  also  a  paralytic  genu 
varum,  due  to  relaxation  of  the  external  lateral  liga- 
ment of  the  knee  from  continued  strain.  The  com- 
monest cause  is  undoubtedly  rickets,  and  the  yielding 
is  oftenest  mostly  below  the  knee,  which  is  the  usual 


338     DEFOEMITIES    OF    LOWER    EXTREMITY 

bow-leg  deformity.  The  greatest  bending  may  take 
place  just  below  the  tibial  tuberosities  (Fig.  165),  or 
at  the  junction  of  the  middle  and  lower  third  (Fig. 
176).  Dane  calls  attention  to  the  fact  that  the  deviation 
of  the  leg  bones  is  inward;  if  the  inner  borders  of  the 
knees  are  placed  in  contact  the  legs  are  crossed.  The 
writer  would  emphasize  the  twist  of  the  tibia  inward, 
which  always  inverts  the  feet,  and  should  be  corrected 
at  the  operation.  During  active  rickets  bow-legged  in- 
fants should  not  be  allowed  to  walk,  and  should  be  treated 
for  the  rickets.     To  walking  children  under  four,  with 


3r^ 

^ 

f^^H 

■ 

I 

11 

^ 

V 

J 

'  JIF^I 

^ 

1 

1 

^^^^^Vl ' 

1 

i 

Fig.  177. — Manual  Osteoclasis  of  Bow-leg  Over  Wooden  Weixje. 

moderate  deformity,  corrective  braces  may  be  applied, 
which  should  extend  to  the  groin  if  the  femora  are  much 
bowed.  Such  braces  consist  of  two  side  bars  as  long  as 
the  leg,  with  a  joint  at  the  ankle,  none  at  the  knee,  a  foot 


THE  XOWER   LEG  339 

piece  slipping  into  the  shoe,  and  a  lacing  drawing  the 
knee  and  leg  toward  the  inner  bar.  When  the  deformity 
is  mainly  below  the  knee,  the  Knight  bow-leg  brace,  sim- 
ilar in  design  but  reaching  to  just  above  the  inner  con- 


^^^^^^^P^^l 

B 

■ 

^^^^■/''^l 

|M| 

^^^H 

^m       1  .. 

BSIpmkH 

^^^H^^l 

-*.  / 

.V  j^Hj^S 

^SHI^v^^NH 

-aL^^ 

^^m 

1^1 

■  ^SI^^^^^^H=  ' 

tm^^^^^^ 

^^ 

wl 

Fig.  178. — Grattan's  Osteoclast  Applied  pok  the  Correction  of  a 

Bow-leg. 

dyle  on  the  inner  side  and  to  below  the  knee  on  the  outer, 
is  used  (Fig.  176).  The  use  of  such  appliances  for  a 
year  or  more  often  corrects  the  deformity.  Indeed,  there 
is  considerable  tendency  to  self-correction,  especially  in 
the  milder  cases.  When  the  deformity  is  severe  or  the 
bones  hard,  even  in  children  as  young  as  three  years, 
the  most  satisfactory  treatment  is  correction  after  osteo- 
clasis or  osteotomy  of  the  tibia.  In  young  children,  when 
the  apex  of  the  deformity  is  in  the  middle  third  of  the 
bone,  the  leg  may  readily  be  broken  over  the  block  by 
the  hands  assisted  by  the  weight  of  the  body  (Pig.  177). 
In  older  children,  or  when  the  fracture  is  to  be  near  the 
knee  or  ankle,  the  osteoclast  will  do  the  work  quickly  and 
without  injury  (Fig.  178).    Once  the  machine  is  adjusted 


340     DEFORMITIES    OF   LOWER   EXTREMITY 


the  plunger  should  be  driven  home  and  released  with 
great  rapidity,  and  if  this  is  done  there  is  no  harmful 
bruising.    After  the  fracture  the  deformity  must  be  o  ver- 

corrected  and  the  feet 
twisted  out,  as  they 
are  always  inverted 
from  a  twist  in  the 
tibia.  The  legs  are 
put  up  in  a  slightly 
knock-kneed  posture, 
in  a  plaster-of-Paris 
splint  from  the  toes  to 
the  groin.  The  splint 
is  left  on  six  weeks, 
and  renewed  once  or 
twice.  The  adolescent 
and  older  cases  are 
best  corrected  by  a 
subcutaneous  osteot- 
omy of  the  tibia  at  or 
above  the  apex  of  the 
curve.  The  technic  is 
similar  to  that  for 
knock-knee;  the  young 
cases  may  also  be  oste- 
otomized,  if  preferred. 
Anterior  curvature  of  the  tibia. {anterior  bow-legs),  is  often 
associated  with  bow-legs  and  knock-knees,  especially  the 
latter ;  all  three  may  coexist  (Fig.  165).  It  may  be  caused 
in  rachitic  children  by  sitting  in  a  chair  with  the  feet  and 
lower  legs  hanging  over.    Most  of  the  bend  is  in  the  lower 


Fig.  179. — Rachitic  Tibial  Recurvature 
WITH  Reversed  Bow-legs.  (Hospital 
for  the  Ruptured  and  Crippled.) 


THE   LOWER   LEG 


341 


half,  and  it  may  be  very  sharp.  Braces  are  usually  use- 
less, but  the  deformity  is  curable  by  osteoclasis  or  oste- 
otomy. The  tibia  should  be  chiseled  and  broken  from  the 
inner  side,  as  in  bow- 
legs ;  afterwards  the  pos- 
terior angle  is  opened  up 
by  forcible  manipulation, 
which  tears  the  perioste- 
um. When  the  tibia  is 
straightened  the  leg  is 
considerably  lengthened, 
and  if  the  deformity  was 
severe  the  foot  will  be 
drawn  down  into  the 
equinus  posture  by  the 
relatively  short  heel 
cord.  When  this  is  the 
case  the  tendo  Achillis 
should  be  cut  and  the 
foot  brought  up  to  a 
right  angle.  A  plaster 
splint  is  then  applied 
from  the  toes  to  the 
groin,  taking  care  to 
retain  the  leg  bones  in 
good  alignment  by  mold- 
ing the  plaster  along  the 
tibial  crests. 

Rachitic  recurvature  at  the  upper  tibial  epiphysis  is  a  rather 
uncommon  deformity,  but  is  occasionally  seen  in  severe 
rickets  (Fig.  179). 


Fig.  180. — Osteoperiostitis  of  Tib- 
ia (Saber -leg)  ;  Hereditary 
Syphilis. 


342     DEFOEMITIES    OF    LOWEE    EXTREMITY 


Several  diseases  of  the  tibia  cause  hypertrophy  and 
anterior  curvature  of  the  bone;  the  principal  ones  are 

syphilis,  ostitis  de- 
formans, and  osteo- 
myelitis. 

In  syphilitic  osteo- 
periostitis the  tibia  is 
enlarged,  elongated, 
curved,  and  some- 
times flattened  on 
one  or  both  sides; 
the  bone  has  a  some- 
what nodular  sur- 
face, and  is  tender 
and  painful  (Fig. 
180).  There  may 
be  suppuration,  but 
more  often  there  is 
none.  The  process 
is  checked  by  anti- 
syphilitic  treatment. 
It  is  commonest  in 
the  second  decen- 
nium. 

In  ostitis  deformans 
{Paget's  disease) 
the  tibia  is  often 
involved,  either  alone  or  with  other  bones.  The  affection 
comes  on  very  slowly,  with  considerable  pain  in  elderly 
people,  and  the  tibia  becomes  much  thickened,  elongated, 
and  curved  (Fig.  181).     There  is  no  suppuration. 


Fig.  181.- 


•Osteitis   Deformans  op   Tibia; 
Local  Form. 


THE   LOWER   LEG 


343 


Osteomyelitis  may  affect  either  end  of  the  tibia  or  the 
shaft.  In  the  latter  form  the  bone  also  becomes  elon- 
gated, thickened,  and  curved  (Fig.  182).  It  is  common- 
est in  children  and  adolescents.  In  a  recent  case,  in  a 
girl  of  twelve,  the  disease  had  existed  about  five  years; 
there  were  numerous  sinuses  leading  to  sequestra,  the 
tibia  was  three  inches  longer 
than  its  mate;  as  the  fibula 


was  not  elongated,  its  at- 
tachment at  the  ankle  forced 
the  tibia  to  bend  forward  at 
its  lower  third.  Diseased 
bone  was  removed  and  de- 
formity corrected  by  sub- 
periosteal resection  of  six 
inches  of  the  shaft.  New 
bone  was  formed,  and  the 
patient  is  making  satisfac- 
tory progress. 

Tumors  and  Cysts. — The 
tibia  is  the  frequent  site  of 
SARCOMA,  especially  near  its 
upper  end. 

OSTEOCHONDEOMATA  SOmO- 

times  develop  from  its  lower 
end.  The  writer  has  seen  a 
BENIGN  CYST  of  the  lower 
end  of  the  tibia,  which  caused  enlargement  of  the 
bone,  but  was  painless  and  without  constitutional  symp- 
toms; there  was  complete  recovery  after  extirpation 
(Fig.  28). 


Fig.  182.  —  Chronic  Osteomyeli- 
tis OF  Right  Tibia,  which  is 
Three  Inches  Longer  than 
THE  Left.  Six  inches  of  the 
shaft  was  resected  subperioste- 
ally,  with  regeneration  of  bone, 
and  good  recovery. 


344     DEFORMITIES   OF   LOWER   EXTREMITY 

Rupture  of  the  plantaris  tendon  occurs  mainly  in  adults. 
If  when  running  or  jumping  a  sudden  stinging  pain  is 
felt  in  the  calf,  followed  by  tenderness,  lameness,  ind 
swelling  and  ecchymosis  at  the  side  of  the  tendo  Achillis, 
it  is  probable  that  the  threadlike  tendon  of  the  vestigial 
plantaris  muscle  has  been  ruptured.  This  accident  causes 
a  good  deal  of  pain  and  disability,  necessitating  the  use  of 
crutches  and  a  light  splint  or  strapping  and  bandage  for 
four  weeks;  recovery  is  complete.  Much  suffering  and 
delayed  healing  result,  if  the  attempt  is  made  to  continue 
the  use  of  the  foot  before  healing  has  taken  place.    ' 

Angina  curls  {intermittent  claudication,  dyshasia  angio- 
sclerotica)  is  due  to  arteriosclerosis  of  the  posterior  tib- 
ial artery;  there  may  be  hardening  of  other  arteries  or 
not.  It  occurs  mostly  in  middle-aged  men  who  are  ex- 
cessive smokers.  It  is  characterized  in  its  typical  mani- 
festation by  the  sudden  onset  of  agonizing  pain  in  the 
calf  when  walking ;  this  may  occur  regularly  after  walk- 
ing a  certain  short  distance,  and  is  so  severe  that  it  is 
impossible  to  proceed.  After  resting  a  few  moments  the 
pain  recedes,  but  it  is  impossible  to  walk  far.  In  typical 
cases  the  pain  does  not  occur  at  other  times.  On  exam- 
ination it  is  found  that  the  posterior  tibial  or  dorsalis 
pedis  pulse  (or  both)  is  diminished  or  absent.  This  may 
also  be  the  case  on  the  opposite  side,  even  if  no  pain 
has  been  felt.  Some  of  these  cases  later  develop  gan- 
grene of  the  foot.  Tobacco  should  be  withdrawn  and 
treatment  for  arteriosclerosis  instituted.  The  attacks 
are  said  to  be  relieved  in  some  instances  by  the  use  of 
the  vibrator,  the  high-frequency  current,  and  other 
means  to  improve  the  local  circulation. 


THE   ANKLE  345 

Varicose  veins  and  varicose  ulcers  of  the  leg  are  not  strictly 
orthopedic,  but  are  both  common  and  troublesome.  The 
veins  may  be  supported  by  strapping,  bandaging  (stock- 
inet bandages  are  best),  lacings,  and  elastic  stockings, 
with  relief  to  the  patient,  but  can  only  be  cured  by  ex- 
tirpation. 

Varicose  ulcers  are  difficult  to  heal  under  the  conven- 
tional treatment  while  the  patient  walks  about,  but  heal 
readily  under  zinc-oxid  adhesive-plaster  strapping.  The 
ulcer  is  covered  and  its  edges  drawn  together  by  over- 
lapping strips  of  one  inch  wide  zinc-oxid  adhesive,  nearly 
encircling  the  leg.  This  dressing  is  to  be  renewed  every 
second  day,  but  no  other  treatment  or  restriction  is  re- 
quired. It  is  astonishing  how  quickly  ulcers  which  have 
resisted  approved  treatment  for  months  or  years  will 
heal  under  this  simple  plan. 

Deformities  of  the  Ankle 

Weak  ankle  (in-anMe)  is  that  posture  of  weakness  in 
which  the  inner  malleolus  descends  and  becomes  promi- 
nent. It  is  often  associated  with  the  outtoeing,  abducted, 
and  everted  foot,  and  also  with  knock-knee.  The  treat- 
ment is  that  of  weak-foot,  under  which  heading  it  is  dis- 
cussed. 

Traumatic  in-ankle  is  discussed  under  valgus. 

Sprain  of  the  ankle  is  a  common  injury  which  consists 
in  the  rupture  of  some  of  the  fibers  of  the  lateral  liga- 
ment, usually  the  external,  of  the  ankle-joint.  Swelling, 
pain,  tenderness,  disability,  and  ecchymosis  follow  rap- 
idly upon  the  injury,  which  is  slow  to  recover  under  local 
applications  or  plaster-of-Paris  splinting.    Soreness  and 

24' 


346     DEFORMITIES    OF    LOWER    EXTREMITY 

lameness  may  persist  for  months.  In  injuries  witli  great 
ecchjTuosis,  fracture  of  the  tip  of  the  malleolus  should 
be  susj^ected,  and  a  skiagraph  taken. 

The  treatment  by  adhesive-plaster  strapping,  intro- 
duced into  this  country  by  Gibney  and  modified  by  Whit- 
man, shortens  the  confinement  and  disability  and  gives 
excellent  final  results.  The  Whitman  method  is  as  fol- 
lows :  So  soon  as  the  patient  is  seen,  two  zinc-oxide  plas- 
ter strips  two  inches  wide  and  twenty-eight  inches  long 
are  snugly  applied  to  the  sides  of  the  leg  beginning  and 
ending  below  the  knee,  covering  the  malleoli,  and  passing 
under  the  heel.  The  foot  is  held  by  these  plaster  strips 
slightly  toward  the  injured  side.  "WTien  the  side  straps 
are  in  place,  strips  of  plaster  one  inch  wide  are  wound 
from  the  ankle  across  the  dorsum  and  under  the  foot, 
and  again  across  the  dorsum  in  the  reverse  direction, 
meeting  the  jooint  of  departure  and  continuing  for  sev- 
eral overlapping  figure-of-eight  turns  with  a  few  circu- 
lar turns  around  the  front  of  the  foot.  This  covers  the 
ankle  and  foot,  excejot  the  heel,  ball,  and  toes,  with  snugly 
applied  overlapping  turns  of  adhesive  plaster.  The  side 
strips  are  held  in  place  by  turns  above  the  ankle,  and 
by  spiral  turns  in  both  directions.  The  leg,  ankle,  and 
foot  are  then  firmly  and  evenly  bandaged  from  the  toes 
to  below  the  knee.  This  dressing  prevents  lateral  strains 
and  checks  swelling,  but  does  not  prevent  the  use  of  the 
foot.  Usually  there  is  marked  relief  from  pain,  and  if 
the  patient  is  inclined  to  use  the  foot  he  may  do  so.  It 
is  probable  that  moderate  use  in  the  firm  dressing  acts 
as  a  kind  of  massage  to  assist  drainage  and  promote 
circulation.    Many  patients  walk  without  discomfort  or 


THE    ANKLE  347 

harmful  effect  so  soon  as  it  is  applied.  In  most  tlie  dis- 
ability is  incredibly  short  and  the  cure  rapid  under  this 
management.  The  dressing  should  be  changed  once  a 
week,  both  for  better  support  and  because  the  skin  may 
become  irritated  if  the  plaster  remains  too  long.  The 
plaster  may  be  loosened  with  alcohol  or  benzine,  and  if 
the  leg  has  been  previously  shaved  the  discomfort  of 
stripping  off  the  plaster  will  be  diminished.  Such  a 
dressing  should  be  worn  for  five  or  six  weeks,  and,  if 
necessary,  followed  by  a  simple  bandage.  Since  the  in- 
troduction of  this  method  the  treatment  of  sprains  has 
been  both  simple  and  satisfactory. 

Tuberculosis  of  the  ankle  usually  occurs  as  an  infection 
from  one  of  the  neighboring  bones,  especially  from  the 
astragalus  or  lower  end  of  the  tibia  (Fig.  183).  In  chil- 
dren this  disease  often  recovers  under  immobilization  of 
the  foot  and  ankle  with  an  ankle  brace  or  with  a  gypsum 
splint,  and  suspension  of  the  limb  by  crutches  or  a  Thomas 
splint,  and  the  usual  tonic  treatment  for  tuberculous  af- 
fections. In  some  cases  sinuses  will  appear  which  may 
heal  under  simple  aseptic  dressings  or  the  occasional  in- 
jection of  a  saturated  solution  of  iodoform  in  ether  or 
the  bismuth-vaselin  mixture.  Sometimes,  however,  the 
ankle-joint  may  have  to  be  opened  and  the  diseased  tis- 
sues removed,  including  the  original  focus;  this  often 
involves  the  removal  of  the  astragalus.  The  location  of 
the  bone  disease  may  be  determined  by  skiagraphy.  In 
adults  the  disease  is  more  often  secondary  to  or  com- 
plicated with  pulmonary  or  other  visceral  tuberculosis, 
and  radical  operations  are  frequently  required. 

A  very  simple  but  efficient  method  of  treatment  of 


348     DEFOEMITIES    OF    LOWER    EXTREMITY 

tuberculosis  of  the  ankle-joint  has  lately  been  employed 
in  Berlin  by  the  advocates  of  the  Bier  method.  A  plaster- 
of -Paris  cast  is  applied  from  the  knee  to  the  ankle  suffi- 
ciently tight  to  cause  slight  congestion,  but  allowing  free 
joint  motion.  The  plaster  is  molded  carefully  about  the 
tuberosities  of  the  tibia;  in  it  is  imbedded  a  double  up- 


-1 

Fig.  183. — Tuberculosis  of  Left  Ankle;  One  Year's  Duration. 
Note  atrophy  of  leg  and  foot. 


right  iron  support,  which  extends  two  inches  below  the 
foot,  with  a  small  foot  plate  to  walk  on.  That  the  ap- 
paratus may  be  easily  removed  and  reaioplied,  it  has  a 
lateral  hinge  on  one  side  of  the  ankle-joint,   and  the 


THE    ANKLE  349 

plaster  is  cut  down  the  front  and  back,  making  two  lat- 
eral halves   (Ogilvy). 

If  the  mechanical  and  hygienic  management  of  the 
case  can  be  carried  out  one  should  not  consent  to  ampu- 
tation so  long  as  the  circulation  in  the  foot  is  good;  an 
excision  of  diseased  bone,  in  case  of  need,  is  preferable 
even  if  it  has  to  be  repeated,  as  ultimate  cure  frequently 
results. 


Fig.  184. — Cure  after  Tuberculosis  of  Right  Ankle  and  Tarsus  by  Con- 
servative Operations  (Gibney)  at  the  Hospital  for  the  Ruptured 
AND  Crippled,  and  Fresh-air  Treatment.  This  patient  had  been  con- 
demned to  amputation. 

The  above  remarks  apply  equally  to  tuberculosis  of 
the  tarsus,  which  is  somewhat  more  serious  and  persistent 
owing  to  the  complicated  structure  and  multiple  joints 
of  the  tarsus  (Fig.  184).  Cures  are  frequently  obtained 
under  conservative  treatment,  especially  in  children. 


350     DEFOEMITIES    OF   LOWEE   EXTREMITY 

Defokmities  of  the  Foot 

Physiological  Anatomy  of  the  Foot 

The  normal  feet  form  a  strong,  flexible,  and  adjustable 
base  for  carrying  the  weight  of  the  body.  The  natural 
foot  is  wedge-shaped,  with  the  apex  at  the  heel;  this  is 
well  seen  in  babies  and  in  primitive  people  who  have 
never  worn  shoes  (Fig.  185) ;  nearly  all  shoe-wearing 
feet  are  more  or  less  deformed.     The  foot  is  rigid  at 


Fig.  185. — Feet  of  Negrito,  Showing  Natural  Shape  When 
Shoes  have  Never  Been  Worn.     (Hoffmann.) 


the  heel,  and  relatively  so  along  the  outer  border;  the 
longitudinal  arch  at  the  inner  side  and  the  transverse 
arch  across  the  ball  should  be  flexible.  The  foot,  in- 
cluding the  toes,  is  naturally  capable  of  considerable 


THE   FOOT 


351 


movement,  and  even  of  prehensile  power,  but  this  is  soon 
lost  under  restrictive  coverings.    It  is  desirable  to  keep 


Fig.  186. — ^Walking  Boot  of  Natural  Shape. 

babies  barefooted  until  they  begin  to  walk,  and  to 
encourage  barefoot  walking  under  suitable  conditions. 
Sandals  have  the  virtues  of  better  ventilation  and  less 
restriction  than  shoes,  and  may  be  worn  a  part  of  the 
time.    Shoes  should  be  laced,  and  of  the  orthopedic  or 


352     DEFOEMITIES    OF   LOWER    EXTREMITY 

natural  shape — i.  e.,  straight  on  the  inner  side,  broad 
across  the  ball,  narrow  and  snug  behind,  but  with  a  low, 
broad  heel    (Figs.   186   and  187).     This   shape   should 


Fig.  187. — Orthopedic  Shoes,  Built  to  the  Lines  op  the 
Normal  Foot. 

be  retained  at  least  for  walking  shoes  in  adult  life. 
"  Right  and  left "  stockings,  longer  on  the  great  toe  side, 
are  also  desirable,  but  are  hard  to  get. 

The  muscles  which  control  the  foot  are  situated  be- 
tween the  knee  and  the  ankle.  Antero-posterior  motion 
takes  place  mainly  at  the  ankle,  rotation  and  lateral  mo- 
tion mainly  at  the  mid-tar  sal  joints.  The  foot  is  arched 
at  the  inner  side,  the  scaphoid  being  the  keystone;  the 
heads  of  the  metatarsals  form  a  transverse  arch,  of  which 
the  pillars  are  the  heads  of  the  first  and  fifth  metatarsals. 
Theoretically  the  foot  is  a  tripod  resting  on  the  os  calcis, 


THE    FOOT 


353 


and  the  heads  of  the  first  and  fifth  metatarsals ;  practi- 
cally the  weight  is  borne  in  most  feet  on  the  heel,  ball, 
and  outer  border.  When  the  foot  is  in  a  normal  con- 
dition, normally  used,  and  supported  by  well-developed 
muscles,  the  inner  border  does  not  touch  the  supporting 
surface  (Fig.  188).    It  is  so  balanced  and  constructed 


Fig.  188. — Sole  Prints  of  Normal  Feet;  Boy  Aged  Six. 


that  diminished  resistance  or  additional  strain  causes  a 
yielding  or  sinking  on  the  inner  side ;  the  inner  malleolus 
sinks,  moves  backward,  and  becomes  prominent,  the  arch 


354     DEFOEMITIES   OF   LOWER   EXTREMITY 

falls  inward,  the  foot  rolls  outward,  and  its  inner  bor- 
der becomes  longer.  This  movement  is  equivalent  to 
an  outward  rolling  (eversion)  of  the  foot  with  abduc- 
tion of  the  forefoot;  the  foot  also  becomes  broader 
across  the  ball  under  weight  bearing.  If  standing  is 
prolonged  on  hard  surfaces,  if  the  load  is  increased  or 
the  muscles  are  weakened,  the  abducted  and  everted  foot 
recovers  less  readily  and  in  time  becomes  a  weak  foot; 
later  from  added  irritation  it  may  become  a  rigid  flat- 
foot.  When  the  foot  gives  out  from  weakness  or  over- 
weighting, it  always  yields  on  the  inner,  the  vulnerable 
side,  in  the  manner  described. 

Walking  with  the  feet  pointing  forward  ( straight-foot 
or  strong-foot  walking),  is  physiological,  graceful,  and 
effective;  it  gives  a  strong  base,  an/elastic  step,  and 
beauty  of  carriage.  The  outtoeing  walk  is  stiff,  ugly, 
and  inefficient ;  it  carries  the  weight  on  the  heel,  gives  a 
bad  base,  and  tends  to  produce  or  aggravate  bad  bodily 
postures. 

The  following  table,  modified  from  WMlnian,  shows 
the  action  of  each  muscle  and  its  relative  importance 
in  each  movement: 


Dorsal 
flexion 

Plantar 
flexion 

Adduc- 
tion 

Abduc- 
tion 

Ever- 
sion 

Inver- 
sion 

Tibialis  anterior 

1 

3 

2 

1 

Extensor  hallucis  longus . . 
Exterior  digitonim  longus. 
Peroneus  brevis 

6 

3 
2 
1 

3 

2 
1 

6 

3 

1 
4 
2 
5 

2 
1 

3 

4 

Peroneus  longus 

Gastrocnemius  and  soleus 

2 

Tibialis  posterior 

3 

Flexor  hallucis  longus 

4 

Flexor  digitorum  longus 

5 

THE    FOOT  355 

Classification  of  Deformities 

Deformities  of  the  foot  exemplify  all  the  postures 
into  which  the  foot  can  be  placed.  The  lateral  deformi- 
ties are  pes  varus  (adduction  of  the  forefoot  with  roll- 
ing in),  and  pes  valgus  (abduction  of  the  forefoot  with 
rolling  out).  The  antero-posterior  deformities  are  pes 
equinus,  when  the  foot  is  dropped,  and  pes  calcaneus, 
when  the  foot  is  raised.  When  the  forefoot  is  dropped 
at  the  mid-tarsal  joints  with  elevation  of  the  arch,  the 
deformity  is  called  cavus.  The  lateral  and  antero- 
posterior deformities  are  frequently  combined;  both 
equinus  and  calcaneus  are  often  associated  with  cavus. 
For  equal  grades  of  deformity  the  valgus  posture  is 
more  disabling  than  the  varus. 

Pes  Varus  and  Equino- Varus. — ^Varus  is  usually  combined 
with  equinus,  pure  varus  being  exceedingly  rare;  the 
combination  is  called  pes  equino-varus,  in  which  either 
the  varus  or  equinus  element  may  predominate. 

Congenital  equino-varus  is  the  commonest  form  of  club- 
foot, and  one  of  the  commonest  congenital  deformities. 
Like  other  congenital  deformities,  it  is  sometimes  inher- 
ited or  appears  in  several  members  of  a  family,  but  it  is 
of tener  isolated ;  it  may  be  associated  with  other  deform- 
ities, but  usually  occurs  in  children  otherwise  free  from 
defect  (Fig.  189).  The  deformity  is  due  in  most  cases  to 
adaptation  to  a  cramped  posture  in  utero  under  uterine 
pressure  from  deficiency  of  liquor  anmii.  It  may  be  uni- 
lateral or  bilateral  or  combined  with  a  calcaneo-valgus  on 
the  other  side ;  in  rare  instances  club-foot  is  combined  with 
club-hands,  due  to  the  same  cause.    The  legs  and  feet  of 


356     DEFOEMITIES    OF   LOWER    EXTREMITY 

club-footed  babies  a  few  days  old  usually  drop  back  read- 
ily into  a  posture  with,  flexed  thighs  and  knees,  in  which 
the  deformed  feet  are  closely  applied  to  the  back  of  the 


Fig.  ISO. — Coxge.mtal  Pes  Equixo-vari-.s.  The  baby  to  the  left  Is  two 
months  old  and  has  the  deformity  on  his  left  side;  the  baby  to  the  right  is 
five  months  old  and  has  both  feet  deformed. 

thighs  or,  by  crossing  the  legs,  to  the  outer  side  of  oppo- 
site knees;  this  is  probably  the  forced  posture  of  the 
last  few  months  of  intrauterine  life.  There  is  in  the 
form  under  discussion  no  primary  defect  in  the  embryo 
and  no  paralysis;  the  foot  has  simply  been  shaped  or 
molded  to  the  posture  forced  upon  it  by  its  constricting 
envelope.  The  deformity  is  of  all  grades  from  very 
mild  to  very  severe;  when  fully  developed  it  presents 
the  following  elements:  (1)  Adduction  of  the  forefoot 
(varus);  (2)  inversion  of  the  foot;  (3)  inward  rotation 
at  the  ankle;  (4)  dropping  of  the  forefoot  (cavus) ;  (5) 
dropping  of  the  foot  at  the  ankle  (equinus).  The  symp- 
toms consist  in  the  deformity  and  consequent  stiffness, 
lameness,  and  disability.    The  leg  muscles  remain  thin, 


THE    FOOT 


357 


and  after  some  years  there  may  be  some  shortening  from 
retarded  growth;  the  foot,  even  when  corrected,  is  usu- 
ally shorter  and  smaller  than  normal.  The  child  walks 
some  months  late,  and  if 
the  feet  have  not  been 
corrected,  it  walks  on 
the  outer  side  of  the 
foot  with  the  toes  point- 
ing inward;  this  aggra- 
vates the  deformity,  and 
the  worst  cases  finally 
walk  on  the  dorsum  of 
the  foot  with  the  fore- 
foot curled  up,  near 
the  internal  malleolus. 
These  severe  imcured 
cases,  though  common 
twenty  years  ago,  are 
now  seldom  seen  in  this 
country.  Walking  on 
deformed  feet  produces 
a  callus  on  the  part  of 
the  foot  receiving  the 
pressure;  it  also  strains 
the  knee,  causing  hyper- 
extension  and  lateral 
weakness. 

Pkognosis.  —  It  will 
appear  from  the  above 

that  the  natural  tendency  of  the  affection,  if  uncorrected, 
is  to  get  progressively  worse,  produce  severe  deformity, 


Fig.  190.  —  Untreated  Case  of  Left 
Congenital  Equino-varus  in  a  Boy 
OF  Six;  Notice  the  Congenital  Con- 
striction Below  Left  Knee  and 
Above  Right  Ankle;  Fingers  are 
Also  Deformed.  (New  York  City- 
Children's  Hospital,  Randall's  Island.) 


358      DEFORMITIES    OF    LOWER    EXTREMITY 

and  make  correction  jDainful  and  difficult  (Figs.  190  and 
191).  Under  mechanical  and  surgical  treatment  most 
early  cases  can  be  entirely  corrected,  and  the  severe  and 
late  cases  greatly  improved. 


Fig.  191. — Untreated  Case  op  Bilateral  Congenital  Equino-varus, 
SHOWING  Extreme  Degree  of  Deformity  in  a  Boy  of  Seventeen. 
(New  York  City  Children's  Hospital,  Randall's  Island.) 

The  TEEATMENT  during  the  first  two  months  of  life 
should  be  confined  to  moderate  manipulation  to  abduct 


THE    FOOT  359 

and  evert  tlie  foot.  At  two  months  of  age,  if  the  baby  is 
healthy,  continuous  mechanical  pressure  against  the  de- 
formity may  be  made  by  metallic  or  plaster-of-Paris 


Fig.  192. — The  First  Application  of  a  Plaster-of-Paris  Splint  to  the 
Unilateral  Case  Shown  in  Fig.  189.  Showing  the  Correction  Ob- 
tained AT  THE  First  Dressing. 

splints  (Fig.  192).  The  foot  is  to  be  gradually  unfolded 
or  remolded  by  overcoming  first  the  varus  element,  later 
the  equinus.  The  foot  may  be  allowed  to  drop  and  lever- 
age applied  by  a  splint  on  the  inner  side  of  the  foot  and 
leg.  The  Judson  splint,  made  of  a  strip  of  brass  with  a 
half  band  at  each  end  properly  padded,  and  a  free  band 
applied  to  the  outer  ankle,  may  be  securely  strapped  to 
the  inner  side  of  the  foot  and  leg  by  adhesive  plaster, 
and  gradually  straightened  as  the  foot  yields  (Figs.  193 
and  194).  This  may  also  be  done  by  a  plaster-of-Paris 
splint  applied  in  the  best  posture  of  the  foot  and  renewed 


360     DEFORMITIES    OF   LOWER    EXTREMITY 

and  straightened  once  a  week.  Violent  stretchings  are  not 
necessary.  When  the  foot  has  been  pushed  out  into  valgus, 
it  will  be  found  that  the  equinus  element  is  diminished, 
and  in  some  instances  may  be  readily  stretched  out  by 
hand  or  by  corrective  splints  of  plaster  or  steel.  It  is  sel- 
dom necessary  or  wise  to  operate  on  a  baby's  foot  during 

B 


Fig.  193. — Progressive  Correction  of  the  Varus  Deformity  by  Con- 
tinuous Leverage  Applied  by  Means  of  the  Judson  Splint.    (Judson.) 

its  first  year,  and  it  is  practically  always  possible  to 
overcome  the  varus  deformity  in  a  few  months.  If  the 
equinus  deformity  is  not  overcome  at  the  age  of  fifteen 
or  eighteen  months,  it  is  best  to  cut  the  heel  cord  subcu- 
taneously,  manipulate  the  foot  thoroughly,  and  put  it 
up  in  overcorrection.  After  the  foot  is  thoroughly  cor- 
rected, rather  somewhat  overcorrected,  the  problem  is 
to  hold  it  until  there  is  no  tendency  to  relapse,  and  at  the 
same  time  let  the  child  walk.  It  is  at  this  point  that 
many  experience  difficulty.    If  the  foot  is  well  held,  the 


THE   FOOT 


361 


pressure  of  walking  will  assist  the  cure,  whereas  if  the 
foot  turns  inside  the  splint,  by  ever  so  little,  walking  in- 
creases this  tendency. 
The  retention  splint 
should  be  applied  to 
the  inner  side  of  the 
foot  and  leg,  sup- 
port the  foot  by  a 
sole  piece,  stopped  at 
a  right  angle,  and 
should  be  secured  by 
strapping  which  is  so 
arranged  as  not  to  in- 
terfere with  the  circu- 
lation. Such  a  splint 
is  the  C.  F.  Taylor 
club-foot  brace,  which 
slips  into  a  laced  shoe, 
and  may  be  adjusted 
by  bending  the  side 
bar  (Fig.  195).  The 
heel  may  be  held  down 
if  desired  by  a  strip  of 
adhesive  plaster  ap- 
plied to  the  inner  side 
of  the  leg,  and  buckled 
to  the  back  of  the 
brace.  This  splint  may 
also  be  used  for  correction,  in  which  case  the  angle  of  the 
foot  part  is  controlled  by  a  screw  stop  at  the  ankle,  and 
is  at  first  applied  in  the  equinus  posture.    Ratchets  and 

25 


Fig.  194. — C.  F.  Taylor's  Method  of  the 
Gradual  Correction  of  Pes  Varus  by 
Continuous  Leverage,  as  Modified  by 
JuDsoN.     (Judson.) 


362     DEFORMITIES   OF   LOWER    EXTREMITY 

complicated  joints  are  unnecessary;  the  vital  point  is  to 
hold  the  foot  to  the  splint,  otherwise  the  foot  turns  inside 
the  splint,  when  correction  is  applied.  In  certain  cases 
after  the  foot  is  quite  presentable  in  shape,  there  may  be 
very  persistent  inversion ;  this  is  usually  due  to  imperfect 
correction  of  the  deformity,  when  additional  correction 
should  be  used,  but  is  occasionally  due  to  an  inward  twist 


Fig,  195. — The  Tayloe  Equino-varus  Brace  with  Adhesive  Plaster  for 
Holding  Down  the  Heel.  If  used  for  retention  the  foot  is  stopped  at  a 
right  angle. 


of  the  tibia.  A  very  effective  splint  for  this  annoying 
condition  consists  of  the  ankle  brace  already  described 
attached  by  a  steel  band  behind  the  calf  to  an  outside  bar 
with  joints  at  the  knee  and  hip,  and  to  a  hip  band ;  this  ap- 
pliance forces  the  foot  out  and  controls  its  direction  (Fig. 
196) .  Cases  seen  in  the  second  to  the  fourth  years  of  life 
and  sometimes  later  may  usually  be  corrected  by  mechan- 


THE    FOOT 


363 


ical  means,  but  much  time  and  annoyance  are  saved  by 
etherizing  the  child,  cutting  the  plantar  fascia  and  heel 
cord  subcutaneously,  and  manipulating  the  foot  thorough- 
ly over  the  wooden  wedge,  or 
with  the  Thomas  wrench  (Fig. 
197).    Ten  to  twenty  minutes 
of   rather  forcible  manipula- 
tion  should   render   the   foot 
quite  pliable,  when  it  may  be 
put  up  in  plaster  in  overcor- 
rection, and  afterwards  held 
by  a  splint.    Many  rigid  cases 
in  older  children  may  be  cor- 
rected by  Phelps's  operation  of 
dividing  all  contracted  tissues 
down  to  the  bone  through  a  cut 
running  from  in  front  of  the 
internal  malleolus  Uvo  thirds 
of   the   way  across   the   sole. 
Eesisting  ligaments  should  be 
divided  even  if  the  astragalo- 
scaphoid  joint  is  opened,  the 
foot  thoroughly  manipulated, 
and    the    deformity    overcor- 
rected.     The  wound  is  covered  with  overlapping  strips 
of  sterile  rubber  tissue,  and  a  large  pad  of  shaken  gauze, 
and  the  foot  put  up  in  plaster.     The  dressing  may  be 
kept  on  four  weeks  or  more ;  the  wound  heals  by  granula- 
tion.    Apparatus  should  be  used  to  prevent  recontrac- 
tion.     A  V-shaped  flap  with  the  point  opposite  the  head 
of  the  first  metatarsal  has  been  used  by  Jonas,  with  divi- 


FiG.  196.— C.  F.  Taylor's  Long 
Club-foot  Splint,  with  Pel- 
vic Band  tor  Outward  Rota- 
tion of  the  Foot. 


364      DEFORMITIES    OF    LOWER    EXTREMITY 

sion  of  deep  tissues  according  to  Phelps,  in  order  to 
cover  the  gap.  Phelps's  operation  is  unquestionably 
safe  and  effective  when  properly  employed ;  it  is  unneces- 
sary in  young  children.  Many  of  the  severe  cases  may 
be  corrected  by  stretching  with  the  Thomas  wrench  or 
other   powerful   instruments,   preferably    after   prelim- 


FiG.  197. — Correction  of  Pes  Equino- varus  bt  Means  of  the  Thomas 
Wrench.    Flat-foot  and  inversion  may  be  overcome  by  an  inward  twist. 

inary  tenotomies.  Schapps  has  recently  debased  a  sim- 
ple but  powerful  lever  for  this  work  (Fig.  212),  and 
excellent  pedoclasts  have  been  shown  by  McKenzie  and 
McCurdy.  The  skillful  use  of  the  means  enumerated 
makes  the  removal  of  wedges  of  bone  rarely  advisable, 
though  this  may  be  safely  done.  T\nien  the  deformed 
astragalus  presents  an  obstacle  to  reduction  its  neck 
may  be  divided,  or  the  whole  astragalus  may  be  removed. 
The  foot  needs  to  be  held  in  position  by  a  brace  for  a 
year  or  two  after  correction.  When  the  brace  is  left  off 
a  slight  tendency  to  inversion  may  be  met  by  building 
the  shoe  up  a  quarter  of  an  inch  on  the  outer  edge. 


THE    FOOT  365 

Paralytic  congenital  club-foot  is  caused  by  a  spina  bifida. 
The  sensory  and  motor  nerves  may  be  permanently 
paralyzed  with  resulting  club-foot.  The  paralysis  may 
be  complete  or  partial  and  is  always  permanent.  The 
deformity  may  be  corrected  by  the  usual  methods,  but  it 
should  be  borne  in  mind  that  on  account  of  the  sensory 
paralysis  continuous  pressure  is  badly  borne,  and  sloughs 
are  easily  produced.  For  this  reason  operative  correc- 
tion is  usually  better  than  mechanical.  The  paralysis 
of  course  remains,  and  retentive  apparatus  is  required. 

The  pes  equino-varus  associated  with  absent  tibia  has  al- 
ready been  mentioned.  The  treatment  is  corrective 
arthrodesis  with  the  lower  end  of  the  fibula.  Pes  equino- 
varus  may  be  caused  by  shortening  of  the  tibia  from 
disease,  by  cicatricial  and  other  contractions  on  the  inner 
side  of  the  foot  and  leg,  by  peroneal  paralysis,  and  by 
spasm  of  the  tibials. 

There  is  no  real  static  varus  or  equino-varus,  except  pos- 
sibly in  barefooted  primitives,  the  condition  popularly 
known  as  pigeon-toes  being  usually  a  compensatory  or 
protective  maneuver  to  ease  the  strain  on  an  in-ankle  or 
an  in-knee;  as  such  it  should  be  inculcated  and  encour- 
aged in  these  conditions.  To  forcibly  turn  the  foot  out- 
ward by  braces  or  shoes  aggravates  the  primary  diffi- 
culty. Another  cause  of  pigeon-toes  is  bow-legs;  here 
the  tibia  invariably  has  a  considerable  inward  twist, 
which  is  always  revealed  when  the  legs  are  placed  on 
a  flat  surface  with  the  patella  pointing  upward.  This 
inward  twist  should  be  rectified  when  the  bow-legs  are 
corrected.  The  pigeon-toed  gait  is  characteristic  of 
spastic  palsy  and  hemiplegia,  the  leg  is  rotated  in  from 


366     DEFORMITIES    OF   LOWER    EXTREMITY 

the  hip  and  turned  in  at  the  foot.  Toeing-in  is  not  usu- 
ally a  serious  deformity,  it  does  not,  unless  excessive, 
interfere  with  good  use  of  the  feet,  and  the  tendency  in 
the  adaptive  cases  is  toward  a  natural  cure. 

Paralytic  equino-varus  is  a  frequent  sequela  of  polio- 
myelitis when  the  peroneal  muscles  are  paralyzed  and 
the  tibials  are  active.  In  mild  cases  the  foot  may  be  held 
by  an  ankle  brace  with  an  outer  T  or  ankle  strap.  The 
deformity  may  be  corrected  in  severer  cases  by  forcible 
manipulation  or  by  tenotomies  of  the  heel  cord  and  plan- 
tar fascia,  and  if  necessary  of  the  tibials.  In  older 
patients  tendon  grafting  or  arthrodesis  may  be  indi- 
cated. A  part  or  the  whole  of  the  anterior  tibial  may 
be  transferred  to  the  outer  side  of  the  foot  and  attached 
to  the  head  of  the  fifth  metatarsal;  or  an  arthrodesis 
may  be  done  at  the  ankle  and  the  calcaneo-cuboid  joint 
with  or  without  tendon  grafting. 

Pes  equinus  is  rare  as  a  congenital  aifection,  but  com- 
mon as  an  adaptive  or  paralytic  deformity.  It  is  often 
combined  with  varus,  and  also  with  cavus.  In  cases  of 
short  leg  from  any  cause,  if  the  shortening  is  not  com- 
pensated by  a  high  sole,  the  foot  is  dropped  and  the 
weight  is  taken  on  the  ball ;  when  this  has  been  done  for 
some  time  the  heel  cord  becomes  permanently  shortened. 
Shortening  of  the  heel  cord  may  also  occur  after  long 
periods  of  recumbency,  when  the  habitual  posture  of  the 
feet  is  in  equinus,  and  also  from  wearing  high  heels. 
Most  women  accustomed  to  wearing  high  heels  have  a 
moderate  adaptive  shortening  of  the  heel  cord.  These 
women  often  cannot  wear  low-heeled  shoes  for  this  rea- 
son.   In  cases  of  weak  and  flat  feet,  although  the  foot 


THE   FOOT 


367 


may  be  easily  pushed  up  to  a  right  angle  and  often  be- 
yond, if  the  foot  is  prevented  from  swinging  into  valgus, 
and  dorsal  flexion  is  made,  the  equinus  becomes  appar- 
ent. Such  a  condition  is  common  in  delicate  and  scoliotic 
children  and  adolescents.  This  condition  has  been  called 
non-deforming  club-foot  (Shaffer),  an  obvious  mis- 
nomer. If  it  requires  a  special  name,  that  of  pes  equinus 
occultus  or  occult  equinus  is  suggested,  though  it  is  no 


Fig.  198. — Paralytic  Equinus  From  Hemiplegia,  Before  and  After 

achillotomy. 

more  hidden  than  mild  degrees  of  many  other  deform- 
ities. Spastic  and  other  forms  of  palsy  are  a  common 
cause  of  equinus  (Fig.  198).  In  cases  of  equinus  second- 
ary to  a  short  leg  one  should  not  correct  the  equinus 
unless  the  leg  can  be  lengthened  or  the  patient  is  willing 
to  wear  a  cork  sole.  It  is  not  always  necessary  to  cor- 
rect degrees  of  equinus  so  mild  as  to  be  occult,  but  it 
is  so  difficult  to   stretch  the  obvious  and  older  cases. 


368     DEFORMITIES    OF    LOWER    EXTREMITY 

that  it  is  far  better  to  perform  the  simple  operation  of 
tenotomy  of  the  heel  cord.  If  preferred,  this  may  be 
done  under  local  anesthesia,  always  under  aseptic  con- 
ditions, but  when  much  stretching  is  required  a  general 
anesthetic  is  better. 

AcHiLLOTOMY. — A  Small  tenotome   (Fig.  199)   is  in- 
serted flatwise   under  the   inner   border   of   the   tendo 


pfc* 


ABC  D 

Fig.  199. — A,  Tenotome  with  Rounded  Edge,  as  Used  at  the  Hospital  for 
THE  Ruptured  and  Crippled,  New  York;  B,  Jones's  Straight-edged 
Tenotome;  C  and  D,  Side  and  Front  View  of  Vance's  Osteotome,  as 
Used  at  the  Hospital  for  the  Ruptured  and  Crippled. 


THE    FOOT 


369 


Achillis  three  quarters  of  an  inch  above  its  insertion 
(Fig.  200).  The  edge  of  the  tenotome  is  then  turned 
toward  the  tendon,  which  is  divided  by  a  sawing  mo- 
tion,  taking  care  not  to   buttonhole  the   skin.     If  the 


Fig.  200. — Subcutaneous  Tenotomy  of  Heel  Corj). 

deformity  is  of  long  standing  the  posterior  ligament  of 
the  ankle-joint  and  other  structures  may  offer  consid- 
erable resistance,  and  much  force  may  be  required  to 
effect  a  correction.  The  heel  cord  may  be  lengthened 
by  an  oblique  cut  and  suturing  through  an  open  incision 
or  subcutaneously  by  splitting  the  tendon  at  two  places 
an  inch  or  two  apart  and  cutting  out  in  opposite  direc- 
tions; the  tendon  is  then  pulled  apart  by  dorsal  flexion 
of  the  foot.  It  is  doubtful,  however,  if  any  operation 
is  better  than  the  simple  subcutaneous  tenotomy,  since, 
if  the  foot  is  placed  at  rest,  the  tendon  always  unites 
firmly  in  six  weeks.  After  the  operation  the  deformity 
should  be  corrected  at  once,  in  congenital  cases  some- 


370     DEFOEMITIES    OF    LOWER    EXTREMITY 

what  overcorrected,  in  paralytic  cases  slightly  under- 
corrected,  and  the  foot  placed  in  plaster-of-Paris  in  the 
corrected  posture. 

Paralytic   drop-foot    (equinus),  if   of   the  flail  variety, 
without  resistance  to  dorsal  flexion,  may  be  held  by  a 


Fig.  201. — Stiff  Two-bar  Ankle  Splint  shown  Applied,  also  Separate 
WITH  Valgus  Ankle-strap  at  Right.  In  the  jointed  splint  at  the  left 
a  stop  prevents  downward  motion. 

stiff  two-bar  ankle  brace,  worn  inside  the  shoe  (Fig. 
201).  If  dorsal  flexion  is  limited  by  the  posterior  leg 
muscles,  the  ankle  brace  may  have  a  stop  to  prevent 
plantar  flexion  only,  or  it  may  be  given  limited  motion 
by  stops  both  ways.  If  there  is  a  varus  or  valgus  an 
outer  or  inner  ankle  strap  may  be  added.  The  drop-foot 
may  be  overcome  by  shortening  the  anterior  tendons, 
and  as  has  been  recently  shown  by  suspending  the  foot 
by  braided  silk  cords  from  the  anterior  surface  of  the 


THE    FOOT  371 

tibia.  The  lower  part  of  the  tibia  is  exposed  and  the 
silk  woven  into  the  periosteum  up,  across,  and  down  for 
a  couple  of  inches;  the  free  ends  hanging  down  are 
drawn  under  the  skin  and  sutured  to  the  periosteum, 
taking  in  a  little  bone  at  the  sides  of  the  scaphoid  and 
cuboid  through  separate  small  incisions. 

Pes  valgus  {abducted  and  everted  foot)  may  be  com- 
bined with  calcaneus  or  with  equinus;  the  latter  condi- 
tion has  been  described  under  equinus;  the  congenital 
form,  usually  combined  with  calcaneus,  is  not  very  rare, 
and  is  usually  curable  by  manipulation.  The  foot  is 
stretched  down  and  in,  and  is  retained  in  plaster  in  the 
equino- varus  posture  if  the  deformity  is  severe.  Valgus 
frequently  follows  a  Pott's  fracture,  which  is  accompanied 
by  displacement  of  the  foot  outward  and  backward,  and 
if  not  corrected  at  the  time  of  the  first  dressing,  the 
displacement  may  become  permanent  and  cause  serious 
disability.  The  foot  should  be  drawn  forward  and  put 
up  in  plaster-of-Paris  somewhat  inverted.  When  this 
is  done,  healing  takes  place  without  deformity.  When 
the  fracture  has  been  allowed  to  heal  in  the  valgus  pos- 
ture, it  may  require  correction  by  refracture,  or  by  an 
osteotomy  above  the  ankle.  Plimpton  advocates  the 
reproduction  of  the  original  fracture  and  the  removal 
of  redundant  callus  by  operation,  in  order  that  the  parts 
may  be  correctly  adjusted;  he  reports  excellent  results. 

Static  valgus,  the  usual  and  normal  result  of  the  yield- 
ing of  weakened  structures,  or  of  passably  healthy  struc- 
tures to  overweighting,  is  one  of  the  commonest  of  de- 
formities. In  its  milder  forms  it  is  known  as  "  weak 
ankles  "  or  "  weak  feet  "  (Whitman),  and  is  very  preva- 


372     DEFORMITIES    OF    LOWER    EXTREMITY 

lent  in  New  York  children  and  in  those  adults  who  stand 
at  their  work;  its  distinguishing  marks  are  prominence 


Fig.  202. — Weak  Ankles  and  Knock-knees  in  a  Young  Child.     (Weigel.) 

of  the  inner  ankle  and  abduction  and  eversion  of  the 
feet  (Figs.  202  and  203).  An  imprint  of  the  foot  may 
be  taken  by  stepping  on  smoked  paper,  or  by  stepping 


Fig.  203. — Weak  Feet  from  Outtoeing.     (Weigel.) 


THE   FOOT 


373 


on  a  ground-glass  plate  or  slate  upon  which  printer's 
ink  has  been  thinly  rolled,  and  afterwards  on  paper; 
the  impression  may  be  fixed  at  once  by  a  spray  of  sic- 
cative (Fig.  204).  In  Freiberg's  method  the  sole  is 
painted  with  the  following  solution: 

Tr.  ferri  chloridi  50 

Alcohol   (80^) 45 

Glycerin  5 


The  patient  then  steps  upon  a 
piece  of  thick  paper  or  card- 
board, after  which  the  im- 
pression may  be  intensified  by 
painting  the  card  with  a  strong 
solution  of  tannic  acid  in  alco- 
hol (Fig.  188).  Such  impres- 
sions show  the  pressure-bear- 
ing surface  of  the  sole.  The 
feet  toe  out,  the  shoes  are 
worn  out  on  the  inner  edge, 
especially  at  the  heel,  and  in 
walking  the  inelastic  heel  gait 
is  used.  In  children  there  is 
seldom  any  pain;  in  adults 
there  often  is,  both  in  the  feet 
and  in  the  legs. 

If  the  feet  are  flexible, 
the  treatment  is  by  exercises, 
proper  shoes,  and  straight- 
foot  walking.  The  shoes  are 
of  the  natural  or  orthopedic 


Fig.  204.  —  Moderate  Flat- 
foot;  Printer's  Ink  Im- 
pression.    (Weigel.) 


374     DEFORMITIES    OF    LOWER    EXTREMITY 


shape,  built  up  a  quarter  of  an  inch  or  slightly  less  on 
the  inner  edge  (Fig.  216) ;  or  the  Thomas  heel,  which 

projects  forward  and  inward  like 
a  buttress,  may  be  used  (Fig. 
205).  The  exercises  are  to  be 
practiced  without  shoes,  and  are 
designed  to  strengthen  the  ad- 
ductors and  invertors.  They  are 
as  follows: 

( 1 )  Walking  with  heels  raised 
and  toes  pointing  inward. 

(2)  Walking  on  the  external 
borders  of  feet;  toes  turned  in. 

(3)  Sitting  with  legs  sup- 
ported and  feet  free,  or  with 
heels  resting  on  floor;  invert 
feet  strongly,  or  grasp  a  large 
ball  between  the  feet. 

(4)  And  best;  stand  with 
feet  turned  in;  quickly  elevate 
heels ;  slowly  come  down  on  outer 
borders  of  feet.  Repeat  fifteen 
or  twenty  times  morning  and 
evening. 

Osgood  has  devised  a  simple 
and  eifective  apparatus  for  exer- 
cising the  muscles  controlling  the 
foot  and  testing  their  strength. 
In  the  atonic  weak  feet  of  adults,  plates  may  some- 
times be  required,  as  it  is  difficult  to  get  patients  to  perse- 
vere with  the  exercises. 


Fig.  205. — Modified  Thomas 
Heel  Extended  For- 
ward AND  Inward,  the 
Mechanical  Equivalent 
OP  the  Turnbd-in  Great 
Toe  of  the  Barefooted 
Primitive.     (Cook.) 


THE    FOOT  375 

Flat-foot. — ^Foot  symptoms  may  come  on  slowly  or  de- 
velop suddenly  in  adult  life,  as  in  women  not  used  to  pro- 
longed standing,  who  adojjt  some  occupation  like  nursing 
which  involves  continuous  standing.  Many  such  begin 
to  have  pain  and  tenderness  under  the  arch,  and  some- 
times over  the  ankles,  under  the  heel,  and  under  the 
outer  ankle  bone  a  month  or  two  after  being  put  to  work. 
Orthopedic  shoes,  built  up  on  the  inner  side,  if  there  is 
a  tendency  to  weakness,  and  straight-foot  standing  and 
walking  are  usually  preventive  of  trouble.  When  feet 
are  painful,  tender,  and  somewhat  stiff,  even  if  the  arch 
has  not  fallen,  they  sbould  be  fitted  with  shoes  built  up 
on  the  inner  side,  be  strapped  in  the  varus  posture,  with 
or  without  a  shaped  felt  pad  under  the  arch,  and  be  put 
at  sedentary  occupations  for  two  or  three  weeks.  The 
strapping  is  done  by  the  method  described  for  supporting 
a  sprained  ankle,  except  that  the  wide  straps  are  started 
below  the  outer  ankle  and  the  foot  drawn  over  into  mod- 
erate varus  (Fig.  206).  If  soreness  subsides  in  a  week  or 
two,  shoBs  and  exercises  will  suffice ;  if  soreness  and  dis- 
ability persist,  casts  should  be  taken  for  foot  plates.  The 
casts  are  taken  by  mixing  a  thick  plaster  cream  and  pour- 
ing it  into  a  pan  or  upon  a  thick  piece  of  paper  just  as  it 
begins  to  set.  The  feet  anointed  with  vaselin  are  placed 
into  this  with  the  inner  borders  parallel  and  two  inches 
apart,  and  pressed  down  about  an  inch  into  the  plaster. 
The  feet  should  be  placed  in  the  posture  which  the  plates 
are  designed  to  give  them — that  is,  slightly  inverted. 
The  soft  plaster  is  molded  up  about  the  feet  with  the 
fingers  to  give  a*  correct  outline.  When  the  plaster  is 
hard  the  feet  are  removed,  and  from  this  negative  a  posi- 


376     DEFORMITIES   OF   LOWER    EXTREMITY 

tive  is  taken.  The  positive  is  shaped  by  scraping  to  dis- 
tribute the  pressure,  and  the  outline  of  the  plate  is  drawn 
upon  it.  To  this  modified  cast  the  plate  of  sheet  steel 
is  fitted.     The  jDlate  which  has  been  found  most  useful 


Fig.  206. — Flat-foot  Strapped  in  the  Posture  of  Inversion. 
(Posed  by  Cilley.) 

by  the  writer  in  mild  and  medium  cases  is  a  long  plate 
without  high  flanges,  reaching  from  the  back  of  the  heel 
to  the  heads  of  the  metatarsal  bones  and  arched  well  up 
in  the  inner  side,  especially  imder  the  scaphoid.  Such  a 
plate  rests  on  the  heel  and  the  anterior  edge.  Its  func- 
tion is  not  only  to  hold  up  the  arches,  but  also  so  to  dis- 
tribute the  weight  that  the  feet  will  be  properly  placed 
and  undue  strain  prevented.  Plates  are  worn  inside 
orthopedic  shoes.  Corrective  exercises  and  straight-foot 
walking  should  be  practiced. 


THE   FOOT 


377 


Rigid  Flat-foot. — In  cases  not  properly  treated  while 
the  feet  are  breaking  down,  abduction  and  eversion  in- 
crease, the  arch  sinks,  and  the  os  calcis  swings  to  the 
inner  side.  The  scaphoid  and  head  of  the  astragalus  slide 
down  out  of  position  or  the  ligaments  yield,  and  the  tar- 
sal bones  acquire  new  bearings  and  new  points  of  pres- 
sure; this  causes  more  or  less  irritation,  soreness,  mus- 
cular spasm,  and  finally  adhesions  and  reshaping  of  the 
bones  and  articulations.  We  have,  then,  in  the  old  rigid 
cases  to  deal  with  fixed  subluxations  of  the  inner  tarsal 
bones  (Fig.  207).  The  first  step  in  the  treatment  is  to 
reduce  the  subluxation  and  restore  the  foot  to  its  nor- 


FiG.  207. — Rigid  Flat-foot,  both  Sides.     (Weigel.) 


mal  posture.  It  is  useless  to  attempt  to  treat  such 
patients  with  plates  or  otherwise  until  the  posture  and 
to  some  extent  the  flexibility  of  the  feet  has  been  re- 
stored.   The  patient  should  be  anesthetized  and  the  foot 

26 


378     DEFORMITIES    OF    LOWER    EXTREMITY 

manipulated,  at  first  in  plantar  flexion,  with  the  help 
of  the  block  and  Thomas  wrench  if  necessary,  and  put 
up  in  plaster-of-Paris  in  adduction  and  inversion  for 
three  or  four  weeks.  The  correction  will  be  much  facil- 
itated by  section  of  the  heel  cord  in  certain  cases.  After 
removal  of  the  plaster,  casts  should  be  taken  for  plates, 
which  in  these  severe  cases  may  often  be  of  AVhitman's 
shape  with  a  large  outer  and  inner  flange  (Fig,  208). 
The  feet  should  be  replaced  in  splints  until  the  plates  are 
applied.  The  patient  should  then  have  shoes  fitted  and 
walk  about,  practicing  the  foot  exercises,  and  have  the 
feet  forcibly  inverted  to  keep  them  flexible  (Fig.  209), 
By  such  measures  as  these  pain,  may  be  relieved,  and  the 


Fig,  208. — ^Whitman's  Plate  Applied  to  Foot:  Plaster  Cast  (Positive) 
OF  Foot,  Marked  for  Plate;  Whitman's  Plate,  and  Long  Plate,  both 
Facing  to  Left, 

patient  enabled  to  walk.  In  many  very  painful  and  use- 
less feet  the  arches  are  not  noticeably  flattened,  and  on 
the  other  hand  many  very  flat  feet  are  useful  and  pain- 
less. This  is  true  in  children  who  seldom  have  pain  from 
flat  feet,  and  also  of  those  feet  that  have  gone  through 


THE    FOOT  379 

the  painful  stage,  and  have  recovered  with  stiff  and  flat 
feet.  Such  feet  in  adults  should  not  be  disturbed,  if 
doing  good  work,  mefely  because  the  arch  is  flattened. 
In  relapsing  cases  characterized  by  much  spasm  of  the 


f1 

N^l 

^^^^^^^^^^^/  ^ 

^^^P^^«~  '^-^ 

Fig.  209. — The  Manipulation  op  Flat-foot  by  Forced  Adduction  and 
Inversion.    (Posed  by  Cilley.) 

peroneals,  the  tendons  of  these  muscles  may  be  hooked 
up  through  an  incision  behind  the  lower  part  of  the  fibula 
and  one  or  two  inches  excised  (Robert  Jones).  This  does 
no  harm,  and  is  often  helpful  in  obstinate  cases.  A  few 
very  flat  and  rigid  cases  are  benefited  by  excising  the 
scaphoid,  which  may  be  done  through  a  longitudinal 
curved  incision  over  its  inner  part.  The  foot  is  then  cor- 
rected, the  wound  sewed  up  and  dressed,  and  in  three 
weeks  a  high  arched  plate  is  fitted.  This  sometimes  gives 
good  results  in  cases  impossible  to  correct  by  manipula- 


380     DEFORMITIES    OF    LOWER    EXTREMITY 

tion  alone.  Commercial  foot  plates  so  freely  offered 
in  shoe  shops  are  usually  inefficient.  It  should  be  remem- 
bered that  many  cases  of  mild  weak  and  flat  feet  mpy  be 
cured  by  proper  shoes  and  corrective  exercises  alone. 
Plates  are  splints,  and  should  not  be  prescribed  in  a 
routine  manner  nor  left  on  indefinitely.  Much  attention 
should  be  paid  to  strengthening  the  foot  with  a  view  to 
leaving  off  the  plates  when  they  are  no  longer  needed. 

*'  Rheumatoid  "  and  Infectious  Flat-foot.  —  Flat-foot  is 
often  mistaken  and  treated  for  rheumatism,  but  flat  and 
painful  feet  are  a  frequent  complication  of  arthritis  de- 
formans. Such  cases  are  much  more  difficult  to  relieve 
than  simple  static  flat-foot.  Weak  or  flat  feet  may  also 
complicate  various  infections,  particularly  gonorrhea. 
These  cases  often  resist  the  usual  treatment,  and  in  all 
obstinate  cases  in  young  adults,  especially  if  unilateral, 
the  possibility  of  gonorrheal  infection  should  be  investi- 
gated. Achillo-bursitis,  tender  enlargement  of  the  os 
calcis,  obstinate  and  painful  swelling  about  the  tarsus, 
and  aggravated  talalgia  with  exostoses  are  frequently 
gonorrheal.  In  such  cases  treatment  of  the  primary 
focus  is  often  of  the  greatest  importance. 

Paralytic  valgus,  due  to  paralysis  of  the  tibial  muscles, 
is  very  common,  especially  after  poliomyelitis ;  it  may  be 
combined  with  shortening  or  lengthening  of  the  heel  cord. 
The  mechanical  treatment  of  paralytic  valgus  is  by  a  two- 
bar  ankle  brace  with  an  arched  sole  plate  and  foot  lacing, 
worn  inside  the  shoe.  The  ankle-joint  may  be  stiff,  lim- 
ited, stopped  up  or  down,  or  free  according  to  the  condi- 
tions. The  ankle  is  drawn  outward  by  a  T  strap  on  the 
inner  side  and  buckled  over  the  outer  bar,  or  by  a  special 


THE    FOOT  381 

ankle  strap.  If  much  force  is  to  be  exerted  a  plate  should 
be  added  at  the  outer  side  of  the  foot  to  make  counter 
pressure.  Such  a  brace  may  be  constructed  with  one 
bar  on  the  outer  side,  and  this  has  the  advantage  of 
easier  adjustment  and  greater  compactness,  but  it  has 
the  disadvantage  of  wearing  down  at  the  joint  and  re- 
quiring more  attention.  Either  arrangement  may  be 
coml)ined  with  a  leg  brace.  When  the  foot  alone  is  to  be 
treated  the  brace  reaches  to  the  upper  part  of  the  calf, 
wliere  it  is  provided  with  a  calf  band  or  side  plate  and 
a  wide  strap  and  buckle,  or  a  lacing.  The  severer  cases 
may  be  improved  by  a  tendon  transference  or  an  ar- 
throdesis, or  both.  If  the  peroneal  tendons  are  active, 
these  may  be  cut  off,  brought  over  the  foot,  and  attached 
to  the  anterior  tibial  or  to  the  periosteum  in  front  of  its 
insertion,  while  the  foot  is  inverted.  It  is  also  possible 
to  reenforce  the  inverting  power  of  the  foot  from  the 
extensor  hallucis  and  from  a  slip  from  the  heel  cord. 
AVhere  all  the  muscles  are  weak,  an  arthrodesis  of  the 
ankle-joint,  and  if  necessary  of  the  astragalo-scaphoid 
joint,  will  give  better  results. 

Dislocation  of  the  peroneal  tendons  occurs  in  some  cases 
of  valgus;  the  tendons  are  dislocated  forward  and  up- 
ward over  the  end  of  the  internal  malleolus.  They  may 
snap  back  and  forth.  If  the  annoyance  is  serious,  a  flap 
of  periosteum  may  be  raised  from  the  fibula  and  sewed 
back  over  the  replaced  tendons,  or  a  groove  may  be  exca- 
vated behind  the  malleolus. 

In  pes  calcaneus  and  calcaneo-valgus  the  foot  is  drawn 
upward  or  upward  and  outward,  and  the  weight  is  borne 
on  the  heel.    In  the  severe  and  long-standing  cases  the 


382     DEFORMITIES    OF    LOWEE    EXTEEMITY 

forefoot  may  drop  down,  causing  a  cavns.  As  already 
described  under  valgus,  the  congenital  form  is  not  very 
rare,  and  the  milder  cases  are  harmless,  as  they  usually 
recover  spontaneously.  The  severer  forms  may  require 
downward  and  inward  manipulation  of  the  foot  and  re- 
tention in  plaster-of 'Paris  in  the  equino-varus  posture. 
It  is  nearly  always  curable. 


Fig.  210. — Paralytic  Calcaneo-valgus  after  Poliomyelitis. 


The  paralytic  form  is  also  not  uncommon ;  in  it  the  foot 
in  front  of  the  heel  is  useless,  even  if  the  toes  can  be 


THE    FOOT 


383 


moved  (Fig.  210).  The  weight  is  borne  entirely  on  the 
heel,  and  the  gait,  provided  there  is  fair  power  at  the 
knee  and  hip,  is  that 


peg   leg, 


of   a 

no    spring 

ticity 


with 

or    elas- 

Indeed    the 


foot  is  worse  than 
useless,  as  it  is 
very  much  in  the 
way.  The  deform- 
ity usually  gets 
progressively  worse, 
the  OS  calcis  becom- 
ing more  vertical, 
the  heel  acquiring 
a  thick  callus,  the 
midfoot  becoming 
highly  arched  (ca- 
vus),  and  the  fore- 
foot a  mere  append- 
age (Fig.  211).  The 
tendency  to  deform- 
ity may  be  checked 
by  a  stiff  ankle  brace 
to  which  the  foot  is 
strapped,  and  which 
transfers  some  of 
the  weight  in  step- 
ping from  the  sole  to  the  front  of  the  tibia  below  the 
knee.  The  wearing  of  such  a  support  mitigates  the  dis- 
ability and  gives  much  relief.    The  patient,  however,  is 


Fig.  211. — Pes  Calcaneo-cavus  and  Flexed 
Knee  in  a  Boy  of  Sixteen,  following 
Poliomyelitis  at  Six  Months  of  Age. 


384     DEFOEMITIES    OF   LOWER    EXTREMITY 

obliged  to  wear  it  for  life.  Shortening  of  the  heel  cord 
alone,  as  advised  by  Willet,  has  not  proved  satisfactory. 

The  most  satisfactory  oj^eration  for  severe  paralytic 
calcaneo-valgus  is  arthrodesis  with  astragalectomy  and 
dislocation  of  the  foot  backward,  as  advised  by  Whitman. 
The  incision  is  Kocher's  fish-hook  incision,  starting  be- 
hind the  fibula  and  curving  under  the  external  malle- 
olus and  over  the  dorsum  of  the  foot  to  the  astragalo- 
scaphoid  joint.  The  peroneals  are  dissected  free,  cut 
off  below,  and  drawn  back.  The  flaps  are  dissected  back 
under  the  tendons  and  the  joint  is  entered  in  front  of 
the  external  malleolus  with  scissors.  Keeping  close  to 
the  astragalus  the  ligaments  which  hold  it  are  cut  by  the 
scissors  one  by  one,  as  the  foot  is  dislocated  inward, 
the  tendons  and  vessels  on  the  dorsum  being  hooked  up 
and  pulled  inward.  The  enucleation  should  not  take 
much  more  than  five  minutes.  The  sustentaculum  tali 
is  then  chiseled  off  and  a  corresponding  place  on  the 
outer  side  of  the  os  calcis  is  freshened,  the  joint  carti*lage 
of  the  tibia,  malleoli,  and  os  calcis  are  then  removed  and 
the  tibia  brought  forward  and  placed  with  the  malleoli 
in  contact  with  the  freshened  sides  of  the  os  calcis,  and 
the  foot  somewhat  plantar  flexed.  The  position  should 
be  stable.  The  peroneal  tendons  may  be  sutured  to  the 
OS  calcis.  .After  closing  and  dressing  the  wound  a  plas- 
ter-of -Paris  splint  is  applied.  A  brace  should  be  worn 
for  a  year  or  more.  The  results  of  tliis  operation  are 
exceedingly  good.  Firm  fibrous  union  in  a  good  posture, 
and  a  much  more  shapely  and  useful  foot  are  usually 
obtained. 

Robert  Jones  has  suggested  an  exceedingly  ingenious 


THE    FOOT 


385 


operation  for  pes  calcaneus  and  calcaneo-valgus  with 
cavus,  which,  however,  requires  two  sittings.  At  the  first 
a  wedge  of  bone  is  removed  from  the  inner  side  of  the 
tarsus  in  front  of  the  internal  malleolus  of  such  shape 


Fig.  212. — Correction  of  Cavus  Deformity  with  Schapps's  Lever.  This 
instrument  may  also  be  adjusted  to  stretch  the  heel  cord,  and  for  lateral 
action. 


(base  mesial  and  dorsal)   as  to  correct  the  cavus  and 
valgus.    The  wound  is  closed  and  dressed,  and  the  foot 


386     DEFOEMITIES    OF   LOWER    EXTREMITY 

brought  up  in  extreme  dorsal  flexion  against  the  tibia 
and  held  in  plaster  four  weeks.  At  the  second  operation 
the  straightened  foot  is  brought  down  into  position  and 
an  ar#irodesis  of  the  ankle  is  done.  This  should  fix  the 
straightened  foot  at  a  right  angle  to  the  leg. 

Pes  Cavus  {Hollow  foot). — Some  individuals  have  an 
exaggerated  arch  and  bear  weight  only  on  the  heel  and 
ball.  Cavus  is  a  frequent  complication  of  equinus,  cal- 
caneus, and  varus.  In  most  cases  where  the  hollow  foot 
is  serious  enough  to  cause  trouble  the  best  treatment  is 
a  subcutaneous  division  of  the  plantar  fascia,  forcible 
stretching  with  the  wrench  if  necessary,  and  fixation  in 
plaster  (Fig.  212).  In  some  cases  of  equinus  combined 
with  cavus,  the  correction  of  the  cavus  may  overcome  the 
deformity.  In  such  cases  it  is  a  mistake  to  divide  the 
heel  cord,  as  the  foot  then  goes  up  en  bloc  when  dorsal 
flexed,  making  it  difficult  to  stretch  the  cavus.  Cavus 
is  often  a  paralytic  deformity. 

In  flail-ankle  when  all  the  muscles  are  paralyzed,  the 
foot  may  be  controlled  by  a  supporting  splint,  or  stiff- 
ened by  an  arthrodesis. 

Affections  of  the  Heel 

Achillobursitis  anterior  involves  the  bursa  between  the 
back  of  the  os  calsis  and  the  lower  end  of  the  tendo- 
Achillis  near  its  insertion.  The  infection  may  be  of  any 
kind  to  which  bursaB  are  subject,  but  is  often  gonorrheal; 
the  bursa  may  also  be  irritated  by  a  tight  or  rough  shoe 
pressing  or  rubbing  the  back  of  the  heel.  There  is  a 
tender  swelling  near  the  insertion  of  the  tendon,  with 
pain  from  shoe  pressure  and  on  walking. 


THE    HEEL  387 

Applications  of  tincture  of  iodin,  adhesive  plaster 
strapjjing,  bandaging,  relief  from  shoe  i)ressure,  and  rest 
will  usually  effect  a  cure.  In  a  tuberculous  or  pus  in- 
fection, the  bursa  will  require  to  be  scraped  out. 

Achillotenontitis  is  an  inflammation  of  the  tendon  itself 
or  its  envelope ;  the  lower  part  of  the  tendon  is  enlarged 
and  tender.  Similar  measures  will  prove  effective ;  rest 
and  the  avoidance  of  stairs  should  be  emphasized.  In 
bandaging  it  is  well  to  place  cotton  pads  either  side  of 
the  tendon. 

Talalgia  and  Osteophytes  of  the  Os  Calcis. — The  os  calcis 
is  not  infrequently  the  seat  of  tuberculous  disease,  which 
requires  the  treatment  outlined  under  tuberculosis  of  the 


Fig.  213. — Bony  Spur  on  Bottom  of  Os  Calcis  in  a  Woman  of  Forty-seven 
WITH  OsTEo-ARTHRiTis.     Relief  after  removal  of  spurs. 

ankle-joint  and  tarsus.  It  is  frequently  the  seat  of  gon- 
orrheal infection,  when  it  is  often  enlarged  and  tender  to 
lateral  and  plantar  pressure.  A  definite  painful  point 
over  the  tuberosity  of  the  os  calcis  may  be  very  persist- 
ent and  troublesome,  and  skiagraphy  shows  that  it  is  fre- 
quently caused  by  irritation  osteophytes,  and  disappears 


388     DEFORMITIES   OF   LOWER   EXTREMITY 

on  their  removal  (Fig.  213).  The  best  approach  is  prob- 
ably by  the  U-shaped  incision  at  the  sides  and  back  of 
the  heel  (Jones).  This  flap  is  turned  down,  the  osteo- 
phytes removed,  and  the  flap  sutured  back  in  place,  leav- 
ing no  scar  on  the  sole.  It  should  be  borne  in  mind  that 
even  when  osteophytes  are  shown,  the  symptoms  fre- 
quently disappear  under  conservative  treatment.  This 
tender  heel  has  been  called  talalgia,  and  has  been  said 
to  be  due  to  a  bursitis.  It  is  a  frequent  accompaniment 
of  flat-foot,  due  no  doubt  to  the  irritation  at  the  inser- 
tion of  the  plantar  ligaments.  It  may  sometimes  be  re- 
lieved by  a  piece  of  felt  cut  out  in  the  middle  like  a  com 
plaster,  or  by  a  foot  plate  made  unusually  concave  at 
the  heel  to  relieve  pressure.  When  the  trouble  is  due 
to  gonorrheal  infection  the  trouble  is  likely  to  be  diffused 
through  the  tarsus,  or  at  least  to  cause  swelling  and  ten- 
derness about  the  astragalo-scaphoid  joint. 

Some  strains  and  wrenches  of  the  foot  result  in  acute 
tenosynovitis  of  the  extensor  or  other  tendons.  The 
affected  tendons  are  tender  and  swollen  and  motion  is 
painful.  Rest,  tincture  of  iodin  locally,  and  a  bandage 
usually  effect  a  cure  in  a  short  time.  Injuries  of  the  foot, 
accompanied  by  much  ecchymosis,  or  pain  at  a  definite 
point  on  a  bone,  should  be  skiagraphed  to  ascertain 
whether  fracture  is  present. 

Hump-foot  (Bradford)  is  caused  by  flexion  at  the  first 
metatarso-cuneiform  joint  with  enlargement  of  the  bones 
on  the  dorsal  surface.  It  is  caused  by  short  shoes  with 
a  high  arch  and  tight  vamp.  Proper  shoes,  rest,  and 
tincture  of  iodin  usually  cure  the  affection,  which  may  be 
quite  painful. 


THE   HEEL  389 

In  hollow  claw-foot  there  is  a  cavus  combined  with 
hyperextension  of  the  proximal  and  flexion  of  the  other 
segments  of  the  toes ;  the  condition  is  usually  associated 
with  paralysis  of  the  interossei  and  lumbricals.  In  order 
to  hold  up  the  forefoot  Sherman  has  devised  the  follow- 
ing ingenious  but  rather  difficult  operation:  The  de- 
formity is  corrected  by  subcutaneous  tenotomy  and 
stretching  of  the  shortened  parts,  and  the  foot  is  i^ut  into 
a  light  plaster  splint.  Care  should  be  taken  to  have  the 
plantar  surface  of  the  splint  thin.  This  is  allowed  to 
harden,  cut  away  on  the  dorsum,  and  protected  by  gauze 
kerchiefs  which  had  been  placed  about  the  foot.  A  large 
fenestra  is  then  cut  over  the  dorsum,  and  a  large  square 
flap  is  raised  back  from  the  base  of  the  toes,  exposing 
the  extensor  tendons;  these  are  cut  as  far  forward  as 
possible,  and  raised.  The  periosteum  over  the  ends  of  the 
metatarsals  is  incised,  raised  to  either  side,  a  chromicized 
gut  suture  with  a  long  needle  at  each  end  passed  through 
the  tendon  back  of  its  cut  end,  and  thus  passed  one  on 
each  side  of  the  bone  through  the  foot  and  plantar  part 
of  the  splint,  tightened,  and  tied  over  a  gauze  pad.  This 
brings  the  cut  end  of  the  tendon  tight  to  the  denuded 
bone.  Each  tendon  is  treated  this  way  in  turn ;  then  the 
flap  is  sutured  in  place  and  the  dressing  applied. 

Eyerson  has  found  that,  by  removing  some  bone  from 
the  dorsum  of  the  metatarsals  by  a  narrow  chisel,  the 
periosteum  may  be  sutured  over  the  cut  end  of  the  ten- 
dons by  means  of  small,  full-curved,  round  needles.  He 
advised  a  looped  stitch  in  the  tendon.  Both  operations 
are  reported  to  give  excellent  results;  the  forefoot  is 
held  up,  and  the  toes  straightened  out  with  the  splinting. 


390     DEFORMITIES    OF    LOWER    EXTREMITY 

Weakness  and  falling  of  the  anterior  arch  of  the  foot  is  a 
very  common  affection.  It  is  often  but  not  always  asso- 
ciated with  weakness  of  the  longitudinal  arch.  In  weak- 
ness of  the  anterior  arch  the  ball  of  the  foot  is  broad- 
ened, and  the  heads  of  all  the  metatarsals  rest  on  the 
ground.  Sometimes  the  middle  metatarsals  seem  to  re- 
ceive more  of  the  weight  than  the  first  and  fifth,  and 
large  and  painful  calluses  are  formed  under  the  middle 
of  the  ball  of  the  foot.  In  other  cases  there  may  be  a 
spot  of  exquisite  tenderness  under  the  fourth,  third,  or 
second  metatarsal,  and  sudden  attacks  of  severe  pain 
running  into  the  toe — Morton's  toe,  metatarsalgia.  The  most 
usual  location  is  the  fourth  metatarsal  and  toe,  and  the 
trouble  is  not  always  associated  with  obvious  weakness 
of  the  anterior  arch;  the  cause  is  probably  a  neuritis  of 
one  or  more  nerve  filaments,  which  are  pinched  by  the 
heads  of  the  metatarsals  as  they  pass  to  the  toe ;  in  other 
cases  there  may  be  joint  irritation.  The  attacks  only 
occur  when  a  shoe  is  worn,  and  it  is  characteristic  that 
the  pain  is  so  great  that  the  shoe  is  at  once  removed,  no 
matter  where  the  sufferer  may  be.  Complete  and  in- 
stantaneous relief  may  sometimes  be  afforded  by  strap- 
ping a  beveled  felt  pad,  three  eighths  of  an  inch  thick 
and  an  inch  or  more  across,  just  behind  the  middle  of  the 
ball  of  the  foot  by  a  one-inch  strip  of  adhesive  plaster, 
encircling  the  foot  behind  the  ball  several  times.  This, 
if  successful,  may  be  replaced  by  a  felt  pad  fixed  to  a 
thin  leather  lacing  to  be  worn  over  the  stocking,  or  by 
a  pad  of  leather  or  hard  felt  just  behind  the  ball  of  the 
foot  in  the  sole  of  the  shoe.  The  shoes  should  be  of 
orthopedic  shape,  wide  across  the  ball,  and  snug  over  the 


THE    HEEL  391 

instep,  with  heel  an  inch  or  more  in  height  and  shank 
well  arched  in  front.  Obstinate  cases  will  require  a  long 
steel  plate  made  from  a  cast  of  the  foot  and  reaching 
from  the  back  of  the  heel  to  the  ball.  The  anterior  part 
of  the  plate  is  arched  from  side  to  side,  and  raised  at  the 
front  to  support  the  metatarsals;  the  longitudinal  arch 
may  be  supported  or  not  as  desired.  Such  plates  may 
be  used  for  weak  anterior  arches  without  Morton's  toe, 
and  indeed  for  many  cases  of  weak  feet.  They  will  also 
prevent  the  formation  of  calluses  on  the  ball  of  the  foot 
by  elevating  the  arch;  should  it  be  necessary  to  soften 
the  callus  or  corns,  collodion  with  ten  per  cent  of  salicylic 
acid,  or  the  official  collodium  salicylatum  compositum,  is 
the  best  application. 

Corns  and  calluses  are  always  due  to  abnormal  pressure, 
often  from  tight  or  badly  shaped  shoes.  They  may  be 
softened  and  scraped  away  after  applications  of  col- 
lodium salicylatum  compositum  (N.  F,),  but  will  recur 
unless  pressure  is  removed  by  fitting  shoes  of  natural 
shape.  Soft  corns  due  to  pressure  between  the  toes  may 
be  difficult  to  cure,  unless  shoes  and  stockings  are  dis- 
carded for  a  time,  and  the  toes  held  apart  by  cotton 
pledgets. 

Chilblains  are  due  to  poor  circulation  often  from  tight 
shoes.  Easy  shoes  should  be  fitted,  and  wide  cotton 
stockings  substituted  for  woolen,  or  vice  versa.  Appli- 
cations of  tincture  of  iodin  and  nitrate  of  silver  are 
sometimes  useful,  but  are  less  important  than  proper 
foot  coverings.  Long  sitting  or  standing  with  the  feet 
on  hard,  cold  floors  is  particularly  harmful. 


392      DEFORMITIES    OF    LOWER    EXTREMITY 

Defoemities  of  the  Toes 

Congenital  deformities  occasionally  occur.  Absence  of 
toes,  metatarsals,  and  tarsal  bones  in  connection  with 
absent  leg  bones  has  already  been  mentioned.  Redun- 
dancy, splitting,  and  fusion  also  occur  (Fig.  214). 


Fig.  214. — Six  Digits  on  Each  Extremity;  Those  on  the  Hands  have 
BEEN  Removed;  Child  of  Sixteen  Months. 

Gigantism  of  one  or  more  toes  with  hypertrophy  of 
the  ball  of  the  foot  is  sometimes  seen,  and  the  foot  is 
sometimes  so  large  and  unwieldy  that  an  amputation  of 
the  enlarged  area  may  be  advisable  (Fig.  215). 


THE    TOES 


393 


The  small  toe  may  be  drawn  upward  and  mesialward 
upon  the  dorsum  of  the  foot.  This  deformity  may  be 
corrected  by  strapping. 

In  split-foot  or  lobster-foot  the  metatarsus  is  split, 
each  prong  carrying  one  or  more  large  and  deformed 
digits. 

Hallux  valgus  is  a  deviation  of  the  great  toe  outward 
with  enlargement  about  the  metatarso-phalangeal  joint. 
This  enlargement  is 
partly  in  the  bursa  and 
soft  parts  (bunion),  and 
partly  in  the  head  of 
the  first  metatarsal. 
This  deformity  is  large- 
ly the  result  of  short 
and  pointed  shoes,  and 
it  destroys  the  value  of 
the  great  toe  as  an  in- 
ward strut  or  brace  to 
oppose  eversion  of  the 
foot.  As  it  seems  im- 
possible to  retain  the 
supporting  power  of  the 

great  toe  with  the  usual  footgear,  our  only  resource 
is  to  replace  it  by  the  elongated  heel  splayed  inward 
(Thomas  heel.  Fig.  205),  which  replaces  to  a  certain 
extent  the  function  of  the  great  toe.  In  moderate  grades 
of  hallux  valgus  orthopedic  shoes  straight  on  the  inner 
side  should  be  worn.  The  toe  post,  a  thin  piece  of 
metal  incorporated  in  the  insole,  may  be  worn  between 
the  great  and  second  toe;  this  necessitates  a  digitated 

27 


Fig.  215. — Congenital  Hypertrophy 
OF  Second  and  Third  Toes  and 
Forefoot  in  a  Baby. 


394      DEFOEMITIES    OF    LOWER    EXTREMITY 

stocking.  A  light  splint  to  pull  the  toe  inward  to  be  worn 
at  night  is  easier  of  adjustment  and  more  manageable 
(Fig.  216).    In  severe  cases  an  operation  is  necessary. 


Fig.  216. — Hallux  Valgus;  the  Toe  to  the  Left  is  Partially  Corrected 
BY  A  Toe  Splint.     The  shoe  is  built  up  on  the  inner  side  for  weak  foot. 

A  great  many  have  been  proposed,  but  oblique  excision 
of  the  head  of  the  first  metatarsal  is  as  good  as  any,  and 
gives  excellent  results.  The  incision  is  convex  upward, 
and  freely  opens  the  joint  at  the  mesial  side  of  its 
upper  surface.  The  head  and  neck  of  the  metatarsal  are 
stripped  of  periosteum  and  ligaments,  and  the  head  is 
cut  off  in  a  slanting  direction  with  the  bone  forceps.  The 
wound  is  sutured  in  two  layers,  and  the  toe  is  held  in 
adduction  by  the  dressings  or  a  small  splint.  The  loss 
of  the  head  of  the  metatarsal  does  not  interfere  with 
the  stability  of  the  foot. 


THE    TOES 


395 


Hallux  varus  occasionally  occurs  as  a  congenital  de- 
formity, but  is  very  common  in  primitive  barefooted 
people,  in  whom  the  prehensile  power  of  the  toes  is 
greatly  developed.  It  also  occurs  as  a  complication  of 
pes  varus,  and  may  be  rather  persistent  after  the  club- 
foot is  practically  cured.  The  ordinary  shoe  of  civilized 
life  usually  corrects  this  deformity. 

In  hallux  rigidus  the  motion  at  the  great  toe-joint  is 
much  limited,  and  the  joint  is  enlarged  and  painful. 
The  skiagram  shows  disappearance  of  cartilage,  and 
sometimes   the   presence  of  osteophytes.     The   process 


Fig.  217. — Hallux  Rigidus  of  Seven  Years'  Duration  in  Man  op 

Forty-five. 

seems  to  be  similar  to  arthritis  deformans,  and  may  be 
the  result  of  an  injury  or  of  repeated  insults  (Fig.  217). 
Strapping,  counter-irritation,  and  protection  or  splinting 
will  sometimes  effect  a  cure,  but  in  certain  cases  it  is 


396      DEFORMITIES    OF    LOWER    EXTREMITY 

necessary  to  excise  the  joint.  A  convenient  form  of 
splint  is  a  thin  bar  of  steel  slipped  between  the  layers  of 
the  sole  of  the  shoe. 

Ingrown  toe-nail  is  an  exceedingly  painful  and  dis- 
abling affection,  for  which  many  ingenious  operations 
have  been  devised.  They  are  all  needless,  as  the  trouble 
is  always  curable  by  protecting  the  soft  parts  from  the 
edge  of  the  nail.  This  may  be  done  in  mild  cases  by  care- 
fully tucking  a  strip  of  kid  or  a  small  piece  of  cotton 
under  the  nail  at  the  side  and  in  front.    In  granulating 

cases,  a  thin  silver  or  alu- 
minium hook,  a  quarter  of 
an  inch  wide  and  bent  on 
the  flat  (Fig.  218),  may  be 
hooked  under  the  edge  of 
the  nail,  protected  by  cotton 
or  gauze,  held  in  place  by 

Fig.    218.  —  Hook    for    Ingrown  ,    .  r?       n       •  i       . 

Toe-nail.     (The  author,  in  the      ^    Strip    of   adhcSlve    piaster, 

American  Medico-Surgical   Bui-      and  alloWCd  to  remain  SOmO 

LPtXTh    I  • 

weeks.  If  properly  adjust- 
ed, the  granulations  contract  and  heal,  and  the  toe  is 
soon  restored  to  its  normal  condition.  The  granula- 
tions may  be  dusted  with  alum  or  aristol.  The  toe  of 
the  boot  should  be  cut  out  to  relieve  pressure,  and  the 
patient  should  be  seen  frequently,  to  change  dressings 
if  soiled. 

Hammer-toes  are  rather  hard  to  manage;  the  affected 
toes  are  sharply  flexed  and  rigid;  if  the  deformity  is 
slight,  manipulation  and  small  splints,  or  supporting 
the  toe  by  adhesive  plaster,  is  sufficient  (Fig.  219).  In 
severe  cases  excision  of  the  joint  and  splinting  the  toe 


THE    TOES 


397 


straight  until  ankylosis  takes  place  is  the  proper  treat- 
ment. Hammer-toe  of  the  first  digit,  or  hallux  flexus, 
may  occur  with  flat-foot. 


Fig.  219. — Correction  of  Mild  Hammer-Toe  by  Adhesive 
Plaster.     (Foote.) 

The  treatment  of  trigger-toes  and  slipping  joints  is 
usually  by  adhesive  plaster  strapping. 


TECHNIC 


TECHNIC 


In  former  days  the  practice  of  orthopedic  surgery 
was  limited  by  some  to  splinting,  by  others  to  splinting 
and  gymnastics,  while  the  operating  surgeon  often  be- 
lieved that  when  he  had  finished  with  a  crippled  patient 
there  was  nothing  further  to  be  done.  It  has  become 
increasingly  evident,  however,  that  in  order  to  do  jus- 
tice to  his  art  the  orthopedic  surgeon  must  be  mas- 
ter of  its  mechanical,  gymnastic  and  surgical  aspects. 
As  gymnastic  and  operative  technic,  so  far  as  they 
come  within  the  scope  of  this  work,  have  already  been 
given,  this  section  contains  an  outline  of  mechanical 
principles,  and  the  details  of  construction  of  such  ap- 
paratus as  will  be  found  most  serviceable  in  general 
practice. 

The  bodily  framework  is  composed  of  a  series  of 
levers — the  long  bones,  moving  on  each  other  at  the 
joints,  actuated  by  the  muscles  or  by  outside  forces,  and 
checked  by  muscles,  ligaments,  and  the  conformation  of 
the  parts. 

In  orthopedic  work  it  is  often  necessary  to  control 
motion  and  pressure  at  certain  joints,  to  progressively 
change  the  posture  of  a  limb,  or  to  fix  it  in  the  posture 
of  choice. 

401 


402  TECHNIC 

LOCAL  PRESSURE  AND  MOTION 

Pressure  may  be  increased  by  bandaging,  strapping,  or 
laced  or  elastic  appliances  encircling  the  parts.  Such 
procedures  give  additional  support  to  weak  or  swollen 
parts  and  hasten  the  absorption  of  simple  effusions;  if 
placed  about  a  joint,  they  also  restrict  motion.  The 
rubber  bandage,  applied  according  to  Bier,  increases 
pressure  in  the  parts  beneath  it,  and  causes  congestion 
in  the  parts  peripheral  to  it. 

Pressure  may  be  diminished  by  quiescence,  recumbency, 
suspension,  and  traction. 

Motion  may  be  increased  by  exercise  and  manipulations. 

It  may  be  restricted  or  abolished  by  voluntary  or  en- 
forced quiescence,  recumbency,  or  splints.  These  dif- 
ferent elements  enter  in  varying  degree  into  the  con- 
ception denoted  by  the  term  protection. 

BANDAGING  AND  STRAPPING 

Some  of  these  topics  are  treated  in  the  general  and 
special  parts  of  this  volume;  it  will  suffice  here  to  dis- 
ci^ss  certain  practical  aspects  of  bandaging,  strapping, 
splinting,  and  traction. 

Bandages  may  be  used  to  keep  dressings,  padding,  ad- 
hesive plaster  or  splints  in  place,  and  to  protect  the  skin ; 
or  they  may  act  like  a  stronger  and  tenser  skin  to  pro- 
duce local  compression  as  in  a  joint  effusion.  When  used 
for  compression,  muslin,  flannel,  or  canton  flannel  band- 
ages are  much  better  than  gauze.  In  applying  bandages 
the  reverse  is  seldom  used;  the  fullness  left  by  changing 


BANDAGING   AND    STRAPPING  403 

the  direction  is  turned  under  as  a  dart.  When  much 
compression  is  desired,  the  bandage  is  drawn  tighter, 
and  it  is  often  well  to  fill  out  hollow  or  soft  spaces  with 
cotton.  If  a  bandage  is  to  remain  long,  it  may  be  re- 
tained in  place  by  spiral  strips  of  narrow  adhesive  plas- 
ter or  by  stitching ;  compression  bandages,  however,  usu- 
ally require  daily  reapplication. 

In  bandaging  the  whole  leg  to  protect  the  adhesive 
plaster  for  the  hip  splint,  three  circular  turns  are 
made  above  the  ankle  to  protect  the  skin  from  the 
buckles;  the  leg  is  then  covered  to  the  groin  with 
ascending  figure-of-eight  turns;  these  are  covered  to 
the  buckles  by  a  descending  spiral.  The  end  and 
each  turn  are  then  stitched  in  place.  Such  a  band- 
age will  prevent  the  plaster  from  slipping,  and  will 
remain  smoothly  in  place  for  a  month  or  two ;  it 
should  not  be  applied  so  tightly  as  to  cause  swelling 
of  the  foot. 

In  using  a  retention  bandage  of  few  turns,  it  is  some- 
times more  stable  if  a  turn  is  passed  through  a  slit  in 
the  preceding  turn  at  the  crossing  (split  bandage,  Grif- 
fith). 

Strapping  with  adhesive-plaster  strips,  which  may  be 
applied  in  overlapping  series  like  clapboards,  or  criss- 
cross, or  both,  one  layer  over  the  other,  affords  even 
better  support  than  a  bandage.  The  best  material  for 
this  purpose  is  zinc-oxid  adhesive  plaster  from  one  to 
two  inches  wide.  The  strips  may  encircle  small  parts 
like  the  finger  or  wrist,  but  should  go  only  three  quar- 
ters around  the  knee  or  leg.  Depressions  may  be  filled 
in,  and  the  whole  should  be  covered  with,  a  bandage. 


404  TECHNIC 

Strapping  may  also  be  applied  over  a  well-fitting  band- 
age to  increase  the  effect. 

The  strapping  of  joints,  particularly  of  sprains,  of 
flat-foot  in  inversion  (Fig.  205),  and  of  varicose  ulcers 
and  inflamed  veins,  as  described  in  the  special  part,  gives 
very  satisfactory  results.  Fractures  of  the  ribs  and 
sprains  of  the  back  may  often  be  sufficiently  sujDported 
by  adhesive  strips  two  inches  wide,  either  imbricated  or 
criss-crossed.  When  mild  compression  is  to  be  used  for 
a  long  time,  it  may  be  applied  by  means  of  a  light  canvas 
lacing  or  an  elastic  covering  fitted  to  the  part.  Diachy- 
lon plaster  on  moleskin  and  zinc-oxid  adhesive  are  much 
used  as  a  basis  for  traction,  and  the  latter  to  secure 
splints  to  the  limb  or  to  fasten  split  splints  together.  It 
is  well  to  cover  with  a  bandage.  Adhesive  strips  doubled 
lengthwise  or  folded  in  from  the  edge  may  serve  as  im- 
provised straps.  If  it  is  desired  that  a  part  of  the  adhe- 
sive surface  should  not  adhere,  as  in  strapping  a  toe 
down  or  up  (Fig.  219),  the  exposed  part  of  the  strip 
may  be  covered  with  a  separate  jDiece  of  the  plaster. 
Strips  of  adhesive  are  often  used  to  retain  dressings. 
Adhesive  plaster  may  be  used  to  cover  or  line  the  ex- 
posed parts  of  steel  splints;  a  few  circular  turns  will 
keep  a  strap  from  slipping  on  a  bar.  Strapping  over  a 
joint,  like  bandaging,  restricts  motion. 

SPLINTING   IN   GENEEAL 

Splints  are  used  to  fix  joints  in  the  posture  of  choice 
or  to  control  pressure  and  the  amount  and  direction  of 
motion.    Fixation  may  be  combined  with  suspension  or 


SPLINTING    IN    GENERAL  405 

traction.    The  underlying  principles  for  splinting  injured 
or  diseased  joints  or  parts  are: 

(a)  Repair  takes  place  better  when  injured  or  dis- 
eased parts  are  at  rest,  at  least  in  the  early  stages.  Lo- 
comotion is  often  undesirable. 

(b)  Healing  or  healed  joints  may  be  used  in  part 
before  they  should  be  intrusted  with  full  function. 

The  underlying  indications  for  splinting  paralyzed  or 
paretic  parts  are: 

{a)  Paralyzed  or  paretic  parts  are  best  placed  for 
recovery  of  strength  if  the  paralyzed  muscle  groups  are 
relaxed  (shortened).  Nothing  so  weakens  a  paretic  mus- 
cle as  continuous  stretching. 

(b)  Locomotion  is  desirable  as  a  general  and  local 
tonic,  and  is  often  possible,  if  the  weak  leg  is  made 
stable,  by  splinting  loose  or  insecure  joints. 

Contractions  of  many  kinds  may  be  gradually  cor- 
rected by  progressively  modifying  the  splint  leverage. 

The  following  mechanical  principles  involved  in  fixation 
splinting  are  for  the  most  part  fairly  obvious;  they  are 
nevertheless  frequently  violated  in  practice. 

(1)  A  fixation  splint  or  lever  must  have  sufficient 
weight  and  stiffness  for  the  work  in  hand;  rigidity  is 
usually  important. 

(2)  A  splint  should  work  from  a  definite  fixed  point; 
the  firmer  the  grasp  the  more  definite  the  effect. 

(3)  The  longer  the  splint  the  greater  the  effect  for 
a  given  pressure. 

(4)  With  a  given  adjustment,  a  splint  will  be  more 
efficient  under  a  moderate  strain,  as  in  quiescence,  than 
under  a  heavy  strain,  as  under  active  motion  or  shaking. 


406  TECHNIC 

(5)  In  splinting,  pressure  and  counter-pressure  must 
be  oi^posite  and  equal. 

Or  more  briefly,  a  si^lint  must  start  somewhere,  go 
somewhere,  and  do  something  on  the  way;  the  means 
employed  must  be  adequate  for  the  results  desired. 

Stiffness. — The  splint  should  be  made  of  suitable 
material  and  weight,  the  latter  proportionate  to  the 
weight  and  activity  of  the  patient,  and  so  distributed 
as  to  resist  the  strains  put  upon  it.  Splints  are  fre- 
quently too  heavy,  and  often  too  light  or  not  stiff  enough. 

Base  and  geasp  are  fundamental,  and  are  much  modi- 
fied by  the  fact  that  the  body  is  not  only  a  combination 
of  levers,  but  that  these  are  constructed  of  and  covered 
by  living  tissues,  which  modify  to  a  certain  extent  the 
working  conditions. 

(a)  The  bony  levers  cannot  be  directly  seized  for  im- 
mobilization, but  are  acted  on  through  layers  of  tissue 
which  are  often  thick  and  soft.  To  hold  the  femur  is 
somewhat  like  trying  to  hold  a  broomstick  inside  of  a 
pillow.  For  this  reason  splints  must  be  accurately  and 
snugly  fitted. 

(b)  Continuous  pressure  on  a  point,  line,  or  small  sur- 
face, especially  when  the  soft  parts  are  thin,  will  pro- 
duce ulceration.  The  points  where  pressure  falls  must 
be  clearly  recognized,  and  chosen  with  some  reference  to 
their  ability  to  bear  pressure.  Sharp  projections  like 
the  spinous  processes,  the  olecranon,  the  back  of  the 
heel,  the  patella,  and  the  malleoli,  should  be  protected 
from  pressure.  The  splint  should  also  be  so  broad  and 
so  well  fitted  at  its  bearing  points  that  pressure  will  be 
evenly  distributed  over  a  comparatively  large  surface. 


SPLINTING   IN    GENERAL  407 

Padding  is  principally  useful  in  that  it  distributes  pres- 
sure and  ensures  a  more  accurate  fit.  It  should  always 
be  remembered  that,  in  order  to  relieve  a  point  of  pres- 
sure, the  pressure  about  it  or  at  some  neighboring 
surface  must  be  increased  (the  iorincii:)le  of  the  corn 
plaster). 

(c)  A  splint  must  not  be  applied  so  tightly  that  it 
will  interfere  with  peripheral  circulation,  causing  swell- 
ing and  necrosis ;  that  is,  circular  constriction  should  be 
avoided. 

Bearing  these  mechanical  limitations  of  bodily  struc- 
ture in  mind,  the  splint  is  held  to  its  proper  base  by  being 
applied  over  a  bent  joint  (knee,  elbow,  ankle),  or  by  be- 
ing molded  or  fitted  above  prominent  parts,  as  the  tro- 
chanters and  iliac  crests,  in  spinal  splints,  by  suspension 
from  adhesive  plaster  applied  to  the  skin  (hip-splints), 
by  attachment  to  webbing  suspended  over  the  shoulders 
(Thomas's  knee  splint),  by  being  held  on  by  bandages, 
adhesive,  or  a  laced  shoe.  In  all  these  methods  the  shap- 
ing and  molding  of  the  splint  so  that  it  will  receive  sup- 
port from  or  be  steadied  by  the  bony  prominences  is  very 
important,  and  in  the  case  of  plaster-of-Paris  splints  en- 
circling the  part,  may  be  alone  sufficient. 

The  grasp  of  the  splint  must  be  firm  or  the  part  to 
be  fixed  will  slip  or  twist  over  it  or  inside  it.  Much 
complexity  of  apparatus  would  have  been  avoided  if  the 
matter  of  grasp  had  been  sufficiently  studied.  The  proper 
placing  of  webbing  or  adhesive  or  other  grasping  appli- 
ances in  a  club-foot  brace  renders  all  screws  and  ratchets 
unnecessary.  Without  proper  grasp  the  foot  inevitably 
twists  out  of  its   splint,  no  matter  how  cleverly  con- 


408 


TECHNIC 


structed.     The  case  is  similar  and  far  more  difficult  in 
scoliosis. 

Length. — The  fixation  splint  should  be  as  long  as 
circumstances  permit  in  order  to  increase  the  leverage. 
Too  short  splints  fail  to  immobilize,  as  sufficient  pressure 
to  fix  the  part  cannot  be  borne.    The  rule  is  to  prolong 


Fig.  220. — Illustrating  Greater  Efficiency  op  Long  and  Carefully 
Fitted  Splints.     (Calot.) 


the  splint  at  least  to  near  the  neighboring  joints,  and  to 
include  them,  if  necessary.  To  fix  the  ankle,  the  splint 
should  reach  from  the  toes  to  below  the  knee;  to  fix  the 
knee,  from  the  ankle  to  the  groin,  or,  better,  from  the 
toes  to  the  lumbar  spine  (Fig.  220). 

Quiescence  or  eecumbency  is  often  a  great  aid  to 
splinting,  and  sometimes  essential  for  a  certain  period. 

It  is  also  necessary  to  consider  the  different  motions 


SPLINTING   IN   GENERAL  409 

at  each  joint  or  point  of  fracture,  and  how  each  is  to  be 
influenced  by  splinting.  For  instance,  rotation  at  the 
hip  may  be  controlled  by  a  splint  having  at  its  upper 
end  a  band  grasping  the  pelvis,  and  at  its  lower  end  a 
foot-piece  holding  the  foot.  Such  an  appliance,  however, 
does  not  control  hip  flexion  and  extension,  or  lateral 
motion.  When  diseased  or  after  a  fracture,  even  a 
hinge-joint,  like  the  ankle,  knee,  or  elbow,  may  require 
fixation  in  all  directions. 

Pressure  and  Counter-pressure. — The  greatest  help 
in  the  technic  of  fixation  or  joint  control  is  a  clear  ap- 
prehension of  the  elementary  mechanics  of  the  problem, 
and  a  definite  plan  for  applying  force  within  the  toler- 
ance of  the  patient,  to  produce  the  desired  result.  The 
basic  principle  in  leverage  teclmic,  and  the  one  that  helps 
one  most  to  obtain  a  clear  and  definite  conception  of 
splint  action  in  a  special  case,  is,  perhaps.  Principle  5; 
pressure  and  counter-pressure  are  opposite  in  direction 
and  equal  in  amount. 

Material. — Fixation  splints  may  be  made  of  plaster- 
of-Paris,  celluloid,  pasteboard,  wood,  stiffened  felt,  pa- 
per, or  leather,  gutta-percha,  mild  steel  wire,  bars,  or 
tubing,  brass,  aluminium,  or  other  material.  They  are 
secured  by  enveloping  the  limb,  by  bandaging,  strapping, 
lacings,  or  straps  and  buckles,  and  are  kept  from  slip- 
ping or  twisting  by  the  means  already  described. 

Plaster-of-Paris  is  the  best  plastic  material  for 
SPLINTS  molded  to  the  body,  on  account  of  its  quick  set- 
ting, lightness,  and  porosity.  Plaster-of-Paris  splints 
are  made  of  crinoline  bandages  from  two  and  a  half  to 
five  inches  wide  and  four  to  six  yards  long,  into  which 

28 


410  TECHNIC 

dental  plaster  lias  been  rubbed.  The  crinoline  should 
run  thirty  to  thirty-five  threads  to  the  inch,  and  may  be 
starched,  but  should  not  be  stiffened  with  dextrine  or 
glue,  which  delay  the  setting.  The  crinoline  may  be 
obtained  in  pieces  thirty  inches  wide  and  twenty-four 
yards  long ;  the  kind  marked  "  Vigilant "  is  used  at 
the  Hospital  for  the  Euptured  and  Crippled.  In  order 
to  avoid  frayed  edges,  threads  should  be  pulled  at  the 
proper  width  for  the  bandage  desired,  and  the  material 
cut  in  the  space  of  the  pulled  thread. 

Plaster-of-Paris  is  pulverized  gypsum  which  has  been 
calcined  at  350°  to  drive  off  water.  It  becomes  inert  if 
exposed  to  moisture  or  cold,  but  may  be  restored  by 
heating  again.  The  dental  casting  plaster  is  the  best 
for  bandages,  but  good  results  are  often  obtained  from 
cheaper  plaster  bought  in  bulk;  the  latter  is  as  good  as 
any  for  filling  casts.  Plaster  should  be  kept  in  tin  re- 
ceptacles in  a  warm,  dry  place.  Good  plaster  will  set  in 
from  five  to  eight  minutes,  and  the  addition  of  salt,  alum, 
or  sulphate  of  potash  to  the  water  is  unnecessary  and 
undesirable,  since  it  weakens  the  splint.  The  addition 
of  one-twentieth  part  of  Portland  cement  (Meisenbach) 
strengthens  the  bandage,  which  may  be  made  lighter  if 
this  small  proportion  of  cement  is  added. 

In  making  the  bandage  the  strip  of  crinoline  is 
loosely  rolled  and  placed  on  a  board,  and  the  plaster 
rubbed  in  by  hand  or  scraped  in  by  a  straight-edged 
knife  or  stick.  It  is  important  that  neither  too  much  nor 
too  little  plaster  be  used;  the  proper  amount  is  just 
enough  to  thinly  cover  the  meshes  of  the  crinoline.  As 
the  bandage  is  finished  it  is  loosely  rolled  up.    If  rolled 


SPLINTING   IN   GENERAL  411 

tight  the  water  will  not  penetrate  sufficiently  to  moisten 
the  bandage.  The  bandages  may  be  prepared  by  a  band- 
age machine,  but  are  hardly  so  good.  Commercial  plas- 
ter bandages  are  for  the  most  part  unsatisfactory. 

Applying  the  Bandage. — The  part  to  which  the  band- 
age is  to  be  applied  is  stripped,  and  covered  with  stock- 
inette tubing  or  a  thin  layer  of  cotton  wadding,  which 
has  previously  been  cut  into  wide  strips  and  rolled  into 
bandage  form ;  absorbent  cotton  may  be  used,  but  is  not 
so  good.  The  padding  is  made  thicker  over  the  points 
of  pressure  and  about  bony  prominences,  in  order  to 
distribute  the  pressure,  and  is  applied  beyond  the  ends 
of  the  splint.  The  cotton  may  be  held  in  place  by  a  snug 
gauze  or  muslin  bandage,  or  this  may  be  omitted. 

For  jackets,  spicas,  and  large  splints,  five-inch  band- 
ages should  be  used;  for  feet  and  smaller  splints,  two- 
and-a-half  to  four-inch  bandages.  A  pail  of  tepid  water 
is  provided,  in  which  the  bandage  is  placed  until  it  is 
thoroughly  soaked;  it  is  well  to  place  the  bandage  care- 
fully on  end  and  to  wait  until  the  water  ceases  to  bubble ; 
it  is  then  taken  out  and  squeezed  at  both  ends,  to  express 
superfluous  water  without  dislodging  the  plaster,  and  to 
work  wdth  the  bandages  fairly  wet,  especially  for  the 
first  layers.  As  each  bandage  is  removed  from  the  water 
it  is  replaced  by  another,  which  soaks  while  the  operator 
is  working.  The  operator  rapidly  applies  the  wet  band- 
age in  spiral,  figure-of-eight,  or  criss-cross  turns,  folding 
in  darts  of  redundant  material,  or  changing  the  direction 
by  bringing  the  bandage  back  on  itself  and  returning  in 
the  direction  of  choice;  if  preferred,  the  bandage  may 
be  cut.     The  bandage  should  be  applied  with  a  snug. 


412  TECHNIC 

even  pressure,  so  that  the  shape  of  the  part  is  preserved ; 
each  bandage  should  overlap  the  preceding  about  two 
thirds.  It  is  a  common  mistake  of  beginners  to  apply  the 
turns  too  loosely,  so  that  the  part  inside  the  padding  is 
not  firmly  grasjoed.  The  bandage  may  be  quite  snugly 
applied,  provided  the  pressure  is  uniformly  distributed 
and  does  not  form  a  constriction  at  any  one  part.  As  the 
turns  are  applied  they  should  be  briskly  rubbed  in  order 
to  cause  the  different  layers  to  fuse  into  one  mass.  The 
method  of  application  is  freely  varied  to  suit  the  con- 
formation of  the  part.  By  making  zigzag  short  turns  of 
the  bandage  on  itself  over  weak  jjarts,  like  the  groin  or 
knee-joint,  the  splint  may  be  strengthened  without  add- 
ing greatly  to  its  weight.  This  may  also  be  accomplished 
by  placing  strips  of  bass-wood  siDlinting,  or  strips  of  tin 
or  thin  steel,  properly  shaped  by  bending  with  the  hands, 
between  the  layers  of  plaster.  When  the  bandage  begins 
to  set  it  becomes  warm,  and  should  then  be  molded  so 
as  to  grasp  the  parts,  and  be  given  its  final  shape,  in 
which  it  should  be  held  without  finger  dents  until  it  is 
hard.  After  the  splint  is  finished  the  ends  are  trimmed 
with  the  scissors  or  a  sharp  knife,  and  if  the  splint  is  to 
be  laced,  it  is  cut  down  the  front,  sprung  open,  and  re- 
moved from  the  part  and  bandaged  together,  to  be  dried 
for  a  day  at  about  300° ;  the  edges  are  then  covered  with 
adhesive  plaster,  kid,  or  buckskin,  and  hooks  are  attached 
to  strips  of  leather,  which  are  sewed  either  side  of  the 
fissure.  The  splint  may  then  be  sprung  open,  replaced, 
and  laced  up.  In  ordinary  work  this  is  not  often  desira- 
ble, except  for  plaster  corsets.  It  is  usually  better  not 
to  split  the  s^Dlint,  and  to  apply  a  new  one  when  a  change 


SPLINTING    IN    GENERAL  413 

of  posture,  inspection  of  the  limb,  or  removal  of  the 
splint  is  necessary. 

Removal. — After  completion  of  a  fixed  splint,  it  is 
well  to  make  a  straight  cut  through  two  thirds  of  the 
thickness  of  the  plaster  down  the  front  before  the  plaster 


1 

K( 

Fig.  221. — Plaster  Splints  Cut  into  Anterior  and  Posterior  Halves. 

is  dry.  This  very  much  facilitates  the  removal  of  the 
splint  without  damaging  it.  Better  still  is  it  often  to 
make  two  cuts,  one  at  each  side  of  the  front.  When  the 
splint  is  to  be  removed  the  cuts  are  completed  and  the 
splint  falls  into  an  anterior  and  a  posterior  half,  allow- 
ing the  part  to  be  removed  without  strain,  and  without 
damage  to  the  splint,  which  may  be  replaced,  strapped 
together,  and  used  again  (Fig.  221).  When  a  splint  is  to 
be  used  and  thrown  away,  the  cutting  oif  is  facilitated 


414 


TECriNIC 


by  wetting  the  plaster  with  warm  water  along  the  strip 
to  be  cut,  which  may  be  easily  done  by  applying  strips 
of  wet  gauze  or  cotton.  The  plaster  may  be  cut  down 
dry  by  cutting  a  V-shaped  groove  with  a  sharp  knife.    A 


Fig.  222. — A.  Stille's  Plaster  Cutter.    B.  Hooks  for  Bending  Steel 
Bars.      C.  Schultze's  Hip-Rest. 

good  knife  for  this  purpose  is  a  cloth  cutter's  knife  with 
replaceable  blades;  it  should  be  sharpened  on  a  strip  of 
emery  paper  after  use.  A  number  of  saws  and  plaster 
cutters  are  in  use,  but  the  most  practical  is  Stille's  plas- 
ter cutter  (Fig.  222),  working  on  the  principle  of  a  con- 
ductor's punch;  the  Swedish  instrument  is  the  best.  It 
will  readily  cut  plaster  a  quarter  of  an  inch  or  more 
thick. 

A  bandage  may  be  left  under  the  splint  next  to  the 
skin,  with  ends  projecting,  to  be  used  for  scratching  the 
skin,  especially  with  jackets  and  spicas  (Lorenz).    Win- 


SPLINTING    IN    GENERAL  415 

dows  may  be  cut  in  plaster  splints  over  sinuses  or  ulcers, 
in  order  to  apply  a  dressing;  or  a  splint  may  be  inter- 
rupted and  bracketed  by  steel  brackets,  incorporated  into 
the  plaster  above  and  below  a  large  sore  or  multiple 
sinuses. 

Care  should  be  taken  to  keep  the  splint  clean  and  dry, 
to  replace  cotton  that  may  have  become  wet  or  soiled, 
and  to  dust  talcum  powder  or  boracic  acid  under  the 
edges.  Spicas  may  be  protected  by  a  muslin  bandage 
or  by  a  stockinette  cover.  A  foul  odor  or  localized  pain 
usually  indicates  a  pressure  sore,  and  the  splint  should 
be  at  once  removed  and  readjusted.  A  plaster  spica  or 
jacket,  if  well  cared  for,  will  keep  in  good  condition  two 
or  three  months. 

A  plaster  bandage,  turned  eight  or  ten  times  upon 
itself  and  rubbed  down  hard,  may  be  applied  to  the  fore- 
arm and  hand,  and  used  as  a  molded  splint;  or  such  a 
band  may  be  used  to  reinforce  a  weak  part — groin,  back 
of  pelvic  part  of  spica,  back  of  ankle,  and  sole  of  foot. 

Instead  of  bandages,  layers  of  crinoline  cut  to  a  pat- 
tern may  be  immersed  in  thick  plaster  cream,  and  ap- 
plied to  the  part  to  be  immobilized.  y^ 

Plaster  Casts. — Other  materials  which  can  be  molded 
require  so  much  time  for  setting  and  drying  that  they 
must  be  shaped  over  a  cast  of  the  part.  A  cast  may  be 
also  used  as  a  record  or  as  a  pattern  to  which  steel  bars 
or  plates  may  be  bent  or  hammered  to  fit  (foot  plates). 
Plaster-of-Paris,  as  it  sets  quickly  and  expands  slightly 
when  setting,  is  best  suited  for  casts.  A  bandage  cast 
is  made  by  applying  a  plaster  bandage  to  the  part  which 
has  been  previously  oiled  or  powdered;  a  thin,  narrow 


416  TECHNIC 

strip  of  aluminium  should  be  laid  on  the  skin  where  the 
bandage  is  to  be  cut  down.  After  the  bandage  is  re- 
moved it  is  greased  or  powdered  with  talc  on  the  in- 
side, the  cast  is  bandaged  together,  the  end  is  stopped 
with  cotton,  or  placed  on  a  board,  and  enough  plaster 
cream  poured  in  to  fill  it.  After  this  has  hardened  the 
shell  is  removed,  leaving  the  mold  of  the  j)art.  If  one 
side  only  of  a  part  is  desired,  it  is  greased  or  powdered 
with  talc,  and  placed  horizontal,  and  to-and-fro  turns 
of  plaster  bandage  are  made  until  a  shell  of  about  eight 
thicknesses  have  been  obtained;  after  setting,  the  posi- 
tive is  taken  as  usual.  This  method  is  not  very  satis- 
factory for  the  hands  and  feet.  Better  results  are  ob- 
tained by  molds  taken  directly  with  thick  plaster  cream, 
as  in 

Casts  for  Foot  Plates. — An  impression  of  the  foot 
may  be  taken  by  pouring  the  thick  plaster  cream  into  a 
pan  or  upon  a  piece  of  thick  paper,  muslin,  or  sheet  of 
cotton  on  the  floor  in  front  of  the  seated  patient.  The 
relaxed  feet,  previously  oiled,  are  then  placed  in  the  plas- 
ter in  the  desired  posture,  and  the  plaster  is  heaped  up 
about  them  and  the  top  smoothed  off  with  the  finger. 
When  the  plaster  is  hard,  the  feet  are  removed  and  the 
positive  taken.  If  the  whole  foot  is  desired,  the  mold  is 
taken  in  two  castings,  while  resting  on  its  outer  side, 
with  the  knee  bent  to  favor  relaxation  and  inversion. 
The  plaster  rests  on  a  pad  of  cotton,  covered  with  mus- 
lin, placed  on  a  stool ;  the  patient's  relaxed  foot  is  placed 
with  the  outer  border  upon  the  thick  plaster  cream, 
which  is  applied  to  about  the  mid  line  of  the  foot;  the 
edge  is   smoothed  with  the   finger  and  greased    (Fig. 


SPLINTING   IN   GENERAL 


417 


223).  A  second  mixture  of  plaster  cream  is  poured 
over  the  foot  to  complete  the  mold,  which,  when  hard, 
comes  off  in  two  lateral  halves.  These  are  bandaged 
together  and  a  pos- 
itive taken.  The 
shape  of  the  plate 
is  marked  off  on 
the  positive,  which 
may  be  shaved  or 
scraped  to  make  it 
-more  concave  and 
narrower  to  fit  the 
shoe.  The  shaving 
of  the  cast  calls  for 
considerable  skill. 
The  impression 
method  is  much 
simpler,  and  is  just 
as  good  if  the  foot 
is  pliable  and  prop- 
erly placed.  Nega- 
tive casts  of  the 
feet  and  hands  and 
other  parts  for  rec- 
ord may  be  made  in 
dorsal  and  plantar 
or  palmar  halves  by  placing  a  thread  about  the  outer 
border  of  the  part  and  pulling  it  so  as  to  cut  the  plas- 
ter before  it  is  hard.  If  the  fingers  and  toes  are  in 
contact,  or  nearly  so,  it  is  not  necessary  to  dip  down 
between  them  with  the  thread. 


Fig.  223. — Taking  Plaster  Cast  for  a  Foot 
Plate.  (Whitman.)  The  cast  is  half 
done. 


418  TECHNIC 

The  arch  supports  (foot  plates)  whicli  have  been 
found  most  useful  by  the  writer  are  the  long  plate  with- 
out flanges  and  the  Whitman  plate  (Fig.  208).  The  long 
plate  is  shaped  to  a  cast  of  the  sole  from  the  end  of  the 
heel  to  the  heads  of  the  metatarsals,  rising  on  the  inner 
side  to  fit  the  longitudinal  arch.  When  used  for  weak- 
ness of  the  anterior  arch,  or  metatarsalgia,  it  is  arched 
up  behind  the  metatarsal  heads  and  under  the  metatar- 
sals. When  used  for  weak  foot  or  atonic  flat-foot,  the 
longitudinal  arch  receives  more  suj)port,  but  the  inner 
side  is  not  arched  up  into  a  high  lateral  flange.  If  de- 
sired, both  anterior  and  longitudinal  arches  may  be  sup- 
ported. Fitted  to  a  cast  taken  with  the  foot  slightly 
inverted,  this  plate  has  given  excellent  results  where  the 
feet  are  not  rigid. 

Eigid  flat-foot  requires  the  Whitman  plate  with  wide 
inner  and  outer  flanges,  after  the  foot  has  been  mobil- 
ized. It  reaches  to  the  tubercle  of  the  os  calcis  behind 
and  to  the  head  of  the  first  metatarsal  in  front ;  the  outer 
side  of  the  front  is  usually  cut  away,  but  may  be  made 
sufficiently  wide  to  give  support  to  the  anterior  arch. 
The  cast  must  be  taken  with  the  feet  well  inverted.  Both 
plates  are  made  of  18-gauge  steel,  cut  to  a  paper  pat- 
tern taken  from  the  marked  cast,  and  hammered  at 
a  red  heat  on  a  cast-iron  last,  and  shaped  to  the  plas- 
ter cast  by  hammering  on  a  lead  block.  The  plates 
should  be  tried  on  and  worn,  and  any  faults  of  fit 
corrected  by  bending  with  a  wrench  or  pounding  with 
a  round-headed  hammer  on  a  lead  anvil.  They  may 
be  tinned  or  zincked,  and  are  worn  loose  in  the  shoe. 
Excellent  plates  have  been  made  of  phosphor  bronze 


SPLINTING    IN    GENERAL  419 

and  other  alloys,  but  they  are  somewhat  thicker  and 
heavier. 

The  plates  are  kept  in  place  by  a  laced  natural-shaped 
or  orthopedic  shoe,  built  up  to  one  eighth  to  one  quarter 
of  an  inch  on  its  inner  side,  if  required.  If  the  foot  slides 
over  too  much  to  the  outer  side,  which  seldom  occurs 
with  proper  shoes,  a  strip  of  thin  piano  felt  three  quar- 
ters of  an  inch  wide  and  three  inches  or  more  long  is 
placed  under  the  lining  of  the  outer  side  of  the  shoe,  the 
front  of  the  strip  reaching  to  just  behind  the  head  of 
the  fifth  metatarsal. 

Celluloid  splints  and  jackets  are  made  by  soaking 
stockinette  or  gauze  in  a  saturated  solution  of  celluloid 
chips  in  acetone.  The  solution  should  be  placed  in  a 
wide-mouthed  bottle,  which  should  be  stirred  from  time 
to  time  and  kept  corked  during  the  intervals.  An  under 
vest  or  piece  of  stockinette  is  drawn  over  the  plaster 
cast  and  the  celluloid  solution  is  painted  on  two  or  three 
times  with  a  brush;  this  is  allowed  to  dry  for  several 
hours,  when  another  under  vest  or  a  layer  of  gauze  band- 
ages is  applied  and  treated  as  before.  Four  or  five  such 
layers  are  needed  for  a  jacket;  when  finished,  the  jacket 
must  dry  for  six  days.  If  removed  too  soon,  it  will  curl. 
The  jacket,  when  finished,  should  be  fitted,  perforated, 
and  trimmed.  Celluloid  splints  are  neat  but  difficult  to 
make,  and  only  moderately  satisfactory.  Celluloid  and 
acetone  are  inflammable,  and  the  fumes  of  the  latter 
are  toxic. 

Leather  splints  and  jackets  are  made  of  unfilled 
oak-tanned  leather,  cut  after  a  pattern,  thoroughly  wet, 
and  stretched  over  a  plaster  cast  of  the  part.    This  wet 


420  TECHNIC 

leather  is  tacked  in  place  and  bound  to  the  cast  by  wind- 
ing with  cord  or  webbing.  It  takes  several  days  to  dry, 
after  which  it  is  stiffened  by  painting  on  hot  bayberry 
wax  until  no  more  is  absorbed.  The  splint  or  jacket  is 
then  provided  with  hooks  and  trimmed  in  the  usual  man- 
ner. Leather  and  celluloid  splints  may  be  reinforced 
with  steel  strips,  if  desired. 

Eemovable  fixation  splints  made  of  steel  bars  on 
either  side  of  the  leg,  ending  in  a  sole  piece  and  i3ro- 
vided  with  cross  bands,  straps,  and  buckles,  and  lined 
with  leather,  are  very  serviceable,  especially  in  cases 
where  exact  control  is  required  and  where  the  brace  is 
to  be  worn  a  long  time.  In  many  instances  it  is  well  to 
make  such  a  splint  with  a  joint,  which  is  at  first  fixed, 
and  in  the  later  stages  of  the  treatment  may  be  given 
limited  or  full  motion. 

This  is  as  good  a  place  as  any  to  say  that  the  way 
an  orthopedic  surgeon  handles  his  steel  work  is  a  pretty 
good  indication  of  his  quality.  The  man  who  sends  his 
patients  to  an  instrument  maker  with  an  order  for  a 
hiiD  splint,  back  brace,  or  what  not,  gets  and  deserves 
to  get  very  indifferent  results.  If  the  case  is  one  for 
mechanical  treatment,  the  mechanical  indications  should 
be  carefully  analyzed,  and  the  apparatus  planned  down 
to  the  minutest  details.  It  is  not  necessary  or  feasible 
for  the  surgeon  to  make  his  own  steel  apparatus,  but  it 
is  indispensable  that  he  should  give  the  instrument 
maker  exact  directions.  It  is  essential  that  orthopedic 
hospitals  should  have  a  machine  shop  and  trained  me- 
chanics. If  a  surgeon  does  not  have  access  to  one  of 
them,  or  has  none  of  his  own,  he  may  still  do  excellent 


SPLINTING   IN    GENERAL  421 

work  with  an  intelligent  locksmith,  gunsmith,  or  black- 
smith and  harness  maker,  provided  he  himself  knows 
what  he  wishes.  He  need  not  be  dominated  by  an  in- 
strument maker  who  has  his  own  idea  of  what  an  appa- 
ratus should  be,  but  a  very  inadequate  conception  of  the 
indications  for  treatment  in  any  particular  case ;  this  the 
surgeon  should  possess,  and  see  to  it  that  it  is  properly 
embodied  in  an  appliance.  The  instrument  maker  will 
furnish  what  the  surgeon  demands,  and  if  the  surgeon 
has  a  clear  conception  of  each  problem  presented,  he  will 
dominate  the  situation,  as  he  should.  As  a  rule,  with 
some  exceptions  it  is  best  to  correct  deformity  by  trac- 
tion in  bed,  forcible  manipulation,  or  surgery,  before  a 
permanent  splint  is  applied.  Many  splints,  particularly 
those  for  the  fixation  of  infected  joints,  require  to  be 
worn  day  and  night  for  months  or  years. 

Elastic  bands,  levers  with  spring  action,  and  axillary 
brace  crutches  are  for  the  most  part  ineffective  or  un- 
necessary, and  form  no  part  of  the  equipment  of  the 
surgeon  who  does  serious  work;  ratchets  are  seldom 
required. 

Measurements. — To  measure  for  a  leg  brace  the  pa- 
tient is  laid  on  his  back  on  a  large  piece  of  smooth 
wrapping  paper,  and  an  outline  of  the  leg  is  taken  with 
a  pencil;  the  sole  is  traced  separately.  The  position  of 
the  ankle,  knee,  crotch,  and,  if  a  hip  band  is  desired, 
of  the  anterior  superior  spine  of  the  ilium  are  noted  on 
the  paper ;  and  if  the  knee  is  bent,  a  side  tracing  is  taken. 
The  outline  of  the  splint  desired  is  drawn  on  the  paper 
close  to  the  tracing  of  the  limb,  and  the  circumferences 
at  the  crotch,  knee,  calf,  and  ankle  are  put  down.    The 


422  TECHNIC 

position  of  the  bands  and  the  kind  of  joints  desired  are 
also  noted.  Such  a  tracing  and  such  measurements,  if 
correct,  will  give  the  instrument  maker  sufficient  data 
from  which  to  construct  the  splint. 

Fitting. — Having  studied  the  mechanical  problem 
and  selected  and  designed  the  proper  splint  to  meet  the 
condition,  it  is  necessary  that  the  splint  should  be  accu- 
rately fitted  to  the  patient.  After  the  steel  frame  is 
made  it  should  be  tried  on  before  it  is  polished,  plated, 
or  lined,  and  such  alterations  made  as  will  enable  it  to 
grasp  the  leg  closely,  yet  without  undue  pressure  on  any 
part.  The  bars  may  be  bent  with  steel  hooks  or  wrenches 
to  relieve  or  increase  pressure  at  any  point  (Fig.  222). 
The  side  bars  may  be  bent  on  the  flat  (laterally)  to  im- 
prove the  fit ;  the  cross  bands  may  be  bent  or  straightened 
to  approximate  or  separate  the  side  bars,  or  where 
a  single  bar  controls  below  the  hip  band  this  may  be 
twisted  to  turn  the  foot  in  or  out.  Very  slight  changes 
often  make  a  vast  difference  in  the  leverage,  comfort, 
and  efficiency  of  the  apparatus;  this  is  especially  true 
of  spinal  splints.  The  splint  should  be  adjusted  until  it 
fulfills  its  function  without  discomfort  to  the  patient. 
Afterwards  the  fit  or  the  leverage  may  be  changed  from 
time  to  time  to  meet  changed  conditions. 

Finishing  and  Lining. — When  the  framework  of  the 
splint  is  finished  it  should  be  japanned,  highly  polished, 
blued,  or  nickel  plated,  lined  with  leather,  and  pads, 
straps,  and  buckles  supplied  where  needed.  While  a  neat 
appearance  is  desirable,  sound  structure  is  the  essential, 
and  many  homemade  or  improvised  splints  render  excel- 
lent service.     Where  there  is  much  pressure  the  skin 


SPLINTING    IN    GENERAL  423 

should  be  bathed  with  alcohol  daily,  dried,  and  powdered 
with  talcum  or  boracic  acid. 

Adjustable  Fixation  Splints. — It  is  often  desirable  to  use 
a  splint  material  that  will  permit  of  angular  adjustment 
as  deformity  is  corrected.  When  plaster  is  used,  if  it  is 
desired  to  change  the  angle  of  fixation  a  new  splint  is 
applied.  The  most  convenient  material  for  such  a  splint 
is  mild  steel  wire,  bars  or  sheets;  aluminium  or  brass 
may  be  used  for  small  parts. 

Strong  STEEL  WIRE  may  be  readily  bent  to  the  size 
and  shape  desired,  usually  that  of  the  outline  of  a  solid 
splint  for  the  part ;  the  wire  is  made  continuous  by  braz- 
ing the  ends  together.  This  wire  skeleton  may  be  cov- 
ered with  bandages  and  padded,  and  may  be  bent  over 
the  edge  of  a  table  to  any  angle,  and  the  angle  changed 
in  an  instant.  It  may  be  bandaged  or  strapped  to  the 
limb.  For  instance,  a  very  serviceable  ankle  splint,  if 
the  leg  is  suspended,  may  be  made  of  wire  following  the 
inner  and  outer  borders  of  the  sole  of  the  foot  and  back 
of  the  leg,  connected  under  the  ball  of  the  foot  and  behind 
the  calf,  and  bent  at  the  heel.  This  splint,  covered  by 
bandages  which  skip  the  heel,  and  padded,  is  light  and  ex- 
tremely convenient  when  there  are  extensive  dressings  at 
or  below  the  ankle.  The  angle  at  the  heel  may  be  changed 
at  will.  Similar  splints  may  be  devised  for  almost  every 
part  of  the  body,  and  almost  every  posture  (Fig.  251). 
The  wire  or  gas-pipe  frame  is  such  a  sjDlint  for  the  entire 
body,  with  special  support  to  the  spine.  Jones  of  Liver- 
pool uses  a  concave  splint  of  mild  steel  of  different 
lengths,  covered  with  felt,  for  routine  splinting,  instead 
of  wood  or  plaster.    These  splints  can  be  bent  in  an  in- 


424  TECHNIC 

stant  over  the  edge  of  a  chair  or  table  to  any  desired 
angle,  and  are  padded  and  bandaged  to  the  limb.  They 
give  excellent  service.  It  is  often  necessary  to  splint  the. 
flexed  knee  and  gradually  straighten  it.  This  may  be 
done  in  an  emergency  by  making  a  posterior  bar  of  flat 
steel  bent  to  the  proper  angle,  and  furnished  at  each  end 
with  a  steel  half  band.  This  may  be  padded  and  strapped 
or  bandaged  to  the  leg,  and  the  angle  straightened  in  an 
instant  as  desired.  The  ready-made  splints  of  the  shops 
are  mostly  unserviceable.  Thin  sheets  of  aluminium 
are  easily  cut  with  the  shears  to  a  pattern,  with  or  with- 
out flanges,  and  are  very  serviceable  for  small  parts,  like 
fingers,  toes,  and  the  wrist.  Phelps  recommended  the 
aluminium  corset  for  spinal  support.  This  is  made  by 
hammering  sheet  aluminium  heated  to  dull  red  over  a 
cast-iron  form  molded  from  a  plaster  cast.  It  is  made 
in  right  and  left  halves,  hinged  behind  on  universal 
hinges,  and  provided  with  hooks  and  lacings  in  front. 
In  spite  of  perforations  they  are  very  hot  in  summer, 
and,  while  they  may  be  made  serviceable,  they  have  never 
seemed  to  the  writer  to  equal  the  plaster  or  steel  and 
leather  appliances.  Simple  small  splints  like  the  Judson 
club-foot  splint  may  be  made  of  brass,  which  is  easily 
adjusted  by  the  fingers. 

The  preceding  discussion  applies  to  simple  fixation 
splints,  fixed  or  removable;  the  elements  of  susioension, 
traction,  and  limited  joint  mobility  frequently  complicate 
the  mechanical  problem. 

Suspension. — It  should  be  noted  that  the  arm  is  already 
suspended.  The  following  remarks  apply  to  the  lower 
limb.    If  it  is  desired  that  the  limb  shall  be  suspended 


SPLINTING    IN    GENERAL  425 

so  that  no  weight  is  borne  by  the  affected  joint,  resort 
may  be  had  to  crutches,  or  to  modifications  of  the  splint, 
which  enable  it  to  transmit  the  weight  from  the  perineum 
to  the  ground  direct.  Two  crutches  should  be  used ;  one 
crutch,  or  a  crutch  and  cane,  are  awkward  combinations 
of  no  real  service.  In  using  crutches  it  is  well  to  take 
the  weight  mainly  upon  the  hands,  for  the  continued 
jDressure  of  the  crutches  upon  the  axillae  frequently  pro- 
duces crutch  palsy.  If  it  is  important  that  the  affected 
limb  should  never  touch  the  ground,  it  is  usually  best  to 
place  a  cork  sole  of  one  to  two  inches  under  the  shoe  of 
the  well  side.  When  partial  use  of  the  limb  is  permitted, 
the  patient  may  walk  between  the  crutches,  gradually 
increasing  the  weight  borne  by  the  affected  limb  as  it 
proceeds  toward  recovery.  When  two  crutches  are  no 
longer  needed,  a  stout  cane  with  a  comfortable  handle, 
used  on  the  well  side,  enables  the  patient  to  relieve  the 
limb  of  about  half  the  pressure.  In  the  alternative  plan 
of  combining  suspension  with  the  fixation  or  protective 
apparatus,  the  splint  is  made  rigid,  is  carried  two  and 
a  half  inches  below  the  foot,  and  a  cork  sole  of  this 
height  is  added  to  the  shoe  of  the  well  side.  The  appa- 
ratus is  provided  at  its  upper  part  either  with  a  rigid 
hip  band  carrying  strong  perineal  straps,  or  with  a 
padded  steel  ring,  upon  which  the  ischium  rests.  The 
Taylor  hip  splint  and  its  modifications  belong  to  the 
former  class,  the  Thomas  knee  splint  and  Phelps  hip 
splint  to  the  latter.  In  either  case  the  leg  hangs  sus- 
pended from  the  perineum  (ischium),  and  all  the  leg 
joints  are  relieved  of  weight  bearing  and  external  pres- 
sure.    It  is  possible  to  accomplish  a  similar  result  by 

29 


426  TECHNIC 

applying  plaster  splints  while  traction  is  made  on  the 
limb,  and  molding  the  plaster  carefully  to  bony  parts 
like  the  tibial  tuberosities  (for  the  ankle),  and  pelvis 
and  perineum  for  the  instep  and  knee;  but  it  is  usually 
easier  and  better  for  the  patient  to  use  a  crutch  with  a 
plaster  splint,  and  let  the  leg  hang. 

Traction  or  continuous  pulling  of  the  leg  was  devised 
with  the  idea  of  relieving  not  only  the  pressure  due  to 
the  weight  bearing,  but  also  that  due  to  local  muscular 
spasm.  When  properly  applied  it  is  extremely  service- 
able during  the  acute  stage  of  many  joint  infections.  In 
hip  tuberculosis  particularly,  intense  suffering  may  fre- 
quently be  instantly  relieved  by  pulling  the  leg  with  the 
hand  (manual  traction).  The  relief  persists  so  long  as 
the  traction  is  kept  up,  and  as  it  is  not  possible  to  do 
this  very  long  by  hand,  adhesive  plasters  are  applied 
to  the  leg,  which  are  fastened  by  buckles  to  a  stirrup 
carrying  a  cord  passing  over  a  pulley  to  a  weight,  the 
patient  being  in  bed.  It  has  been  shown  experimentally 
that  the  surfaces  of  the  hip-joint  may  be  separated  by 
traction;  in  most  instances  it  suffices  to  relieve  the  pres- 
sure. Lateral  traction  is  unnecessary.  The  technic  of 
weight  and  pulley  traction  in  bed  is  simple,  but  impor- 
tant. The  adhesive  plasters  should  be  evenly  applied 
nearly  to  the  groin;  if  they  do  not  reach  high  enough, 
injurious  strain  comes  upon  the  knee.  If  the  thigh  is 
flexed  or  adducted,  the  leg  is  placed  upon  an  inclined 
plane,  and  the  weight  and  pulley  so  arranged  as  to  pull 
in  the  line  of  the  deformity  (Fig.  151) ;  the  knee  should 
be  slightly  flexed.  Symptoms  are  frequently  aggravated 
by  pulling  against  the  hip  deformity.     As  the  muscles 


SPLINTING    IN    GENERAL  427 

gradually  relax  to  the  traction,  the  pulley  is  lowered  un- 
til the  pull  is  in  line  with  the  bed  and  the  body.  Five 
or  six  pounds  in  a  sand  or  shot  bag,  flat  iron,  or  brick  is 
usually  sufficient  for  a  child;  ten  or  twelve  j^ounds  for 
an  adult.  It  is  important  that  the  feet  should  not  touch 
the  foot  of  the  bed  or  the  weight  touch  the  floor ;  a  metal 
bedstead  is  the  most  convenient,  and  should  be  long 
enough  to  allow  six  or  eight  inches  space  below  the 
foot;  the  mattress  should  be  hard  to  prevent  sagging. 
If  necessary,  thin  boards  may  be  placed  under  the  mat- 
tress. To  prevent  the  patient  from  being  drawn  down- 
ward by  the  i^ull  of  the  weight,  the  foot  of  the  bed 
should  be  elevated  six  to  eight  inches,  or  the  patient 
should  have  counter-traction  from  perineal  straps  at- 
tached to  a  frame  or  to  the  bed.  At  the  Post-Graduate 
Hospital,  in  addition  to  raising  the  foot  of  the  bed,  a 
towel  is  pinned  around  the  patient  below  the  ribs,  and 
the  back  of  this  is  fastened  to  the  head  of  the  bed  by  a 
bandage;  this  plan  works  well  in  practice.  For  traction 
of  the  bent  knee  a  double  inclined  plane  may  be  used,  or 
a  curved  rod  may  be  passed  lengthwise  over  the  bed, 
from  which  traction  may  be  applied  upward  and  head- 
wise  above  the  knee  and  upward  and  footwise  below  the 
knee  (to  overcome  backward  subluxation),  and  down- 
ward and  footwise  from  the  knee  to  the  ankle.  Trac- 
tion in  bed  is  also  useful  to  stretch  contracted  parts 
which  are  not  infected,  as  in  resistant  cases  of  congenital 
hip  dislocation.  In  the  last  class  of  cases  two  to  four 
weeks  are  sufficient;  in  hip  diseases,  a  few  weeks  to  a 
few  months.  Head  traction  in  bed  or  on  a  frame  by  means 
of  a  head-halter,  and  weight  and  pulley,  is  sometimes 


428  TECHNIC 

advisable  in  cervical  and  upper  dorsal  disease  of  the 
spine,  but  it  is  probable  that  the  traction  does  good  in 
most  cases  by  the  incidental  immobilization,  as  the  ef- 
fects of  traction  on  the  spine  are  usually  best  produced 
by  leverage.  Moderate  traction  may  be  applied  to  the 
hip  by  means  of  a  close-fitting  spica  grasping  the  pelvis 
and  condyles,  and  to  the  knee  by  a  snug-fitting  plaster 
splint  grasping  the  thigh  or  pelvis  and  foot.  The  action 
of  such  an  appliance  is,  however,  uncertain  and  transi- 
tory, owing  to  the  indefiniteness  of  "the  grasp,  and  con- 
sequent slipping  of  the  part.  Spinal  traction  by  a  pro- 
tective appliance,  like  a  plaster  jacket  and  head  spring, 
is  likewise  illusory,  though  such  an  apparatus  may  serve 
a  good  purpose  by  its  leverage  action. 

Portative  traction  splints  are  usually  made  of  a  stiff, 
steel  framework,  properly  lined  and  fastened  by  straps 
and  buckles;  they  differ  from  the  fixation  apparatus, 
which  also  furnishes  suspension  by  the  introduction  of 
a  ratchet  or  other  device  by  which  a  continuous  pull  is 
exerted.  Suspension  of  the  leg,  indeed,  provides  trac- 
tion by  the  weight  of  the  leg,  so  long  as  the  body  is 
upright,  and  at  night  or  when  recumbent  a  weight  may 
be  attached  to  the  limb.  The  traction  may  also  be  in- 
creased by  tightening  the  straps  by  which  the  lower  end 
of  the  apparatus  is  attached  to  the  adhesive  plasters, 
the  upper  end  being  fixed  by  a  perineal  ring  or  straps. 
In  fact,  a  ratchet  introduced  at  the  side  of  the  leg  bar, 
as  in  the  Taylor  hip  splint,  has  proved  mainly  useful  in 
adjusting  the  brace,  and  it  has  been  abundantly  proven 
in  practice  that  good  fixation,  suspension,  and  the  simple 
adjustment  of  straps  and  buckles  are  sufficient  in  the 


SPLINTING    IN    GENERAL  429 

ambulatory  stage  of  treatment  without  special  traction 
devices.  If  more  than  this  is  required  it  is  better  to 
give  the  patient  weight  traction  in  bed  for  a  few  weeks, 
either  with  or  without  a  hip  splint,  and  let  him  get  up  on 
the  fixation  and  suspension  apparatus  snugly  strapped, 
and  usually  with  crutches,  after  the  muscular  spasm, 
pain,  and  acute  symptoms  have  abated. 

Limited  motion  at  certain  stages  or  for  certain  condi- 
tions is  frequently  indicated  when  either  fixation  or  free 
motion  would  be  harmful,  and  it  is  often  wise  to  per- 
mit motion  in  certain  directions  while  preventing  it  in 
others.  To  introduce  controllable  motion  an  appliance, 
usually  of  steel  and  leather  with  proper  strapping,  is 
used,  which  resembles  a  fixation  apparatus  for  the  part 
except  that  it  is  provided  with  a  joint  or  joints.  It  is 
especially  to  be  remembered  that  a  movable  apparatus 
must  be  heavier  and  stronger  than  a  simple  fixation  ap- 
pliance, especially  as  it  must  bear  the  strain  imposed  by 
the  body  weight,  which  the  other  frequently  does  not.  It 
must  also  conform  to  the  rules  for  grasp,  incidence  of 
pressure,  and  length  laid  down  for  fixation  appliances. 
A  joint  may  be  a  simple  lap  joint  made  by  joining  the 
flat  ends  of  two  pieces  of  steel  by  a  pin  or  pivot,  or  a 
fork  or  hinge  joint,  where  one  end  of  the  bar  passes  be- 
tween a  fork  in  the  other  bar,  the  three  flanges  being 
pivoted  together.  Such  joints  are  harder  to  make  and 
are  much  more  expensive,  but  if  well  made  are  more 
durable.  A  free  joint  is  one  without  stops.  A  stop  joint 
is  one  provided  with  stops  to  limit  motion.  For  instance, 
a  two-bar  ankle  brace  may  have  no  joints  (fixation 
splint),  or  may  have  a  joint  permitting  free  antero-pos- 


430 


TECHNIC 


terior  motion  at  the  ankle,  in  which  case  it  prevents  lat- 
eral motion  only;  or  it  may  have  an  up  stop  to  prevent 
dorsal  flexion  (in  calcaneus)  or  a  down  stop  to  prevent 
plantar  flexion  (in  equinus),  or  both  stops  to  limit  an- 
tero-posterior  motion  in  both  directions  (Fig.  224). 


& 


& 


o. 


o 


o 

oY/o 


(S. 


Fig.  224. — Different  Splint  Joints  at  Ankle.  A.  No  joint.  B.  Free 
joint.  C.  Down  stopped  joint.  D.  Up  stopped  joint.  E.  and  F. 
Limited  motion  joint.     G.  Slip  joint. 

A  stopped  joint,  especially  when  the  stop  is  designed 
to  resist  the  weight  of  the  body,  should  be  stronger  than 
a  free  joint. 

Snap  joints  are  used  to  give  fixation  when  standing 
and  walking,  and  yet  allow  flexion  when  sitting  (Fig. 
225).  They  are  used  particularly  in  supporting  splints 
for  the  knee,  with  quadriceps  paralysis.  A  strong  joint 
is  made  with  a  steel  disc  riveted  to  the  lower  bar  on  the 
inner  side ;  this  disc  and  the  upper  bar  are  perforated ;  a 
steel  lever  five  or  six  inches  long  is  pivoted  to  the  upper 
segment  of  the  splint  on  the  outer  side;  the  lower  end 
of  this  bar  is  split,  and  carries  a  pin,  pivoted  in  the 
fork,  at  right  angles  and  fitting  in  the  perforations  of 
the  side  bar  and  disc.  When  the  pin  is  in  the  holes, 
the  brace  is  without  joint  motion;  when  the  pin  is  with- 


SPLINTING— SPECIAL 


431 


drawn  from  the  hole  in  the  disc  by  pressing  on  the 
upper  end  of  the  small  lever,  the  knee  may  be  bent  at 
any  desired  angle ;  the 
pin  snaps  into  place 
automatically  from 
the  outward  pressure 
of  a  spring  on  the  up- 
per end  of  the  lever, 
when  the  holes  come 
opposite  as  the  brace 
is  straightened.  Such 
a  splint  may  be  set  at 
any  angle,  and  mo- 
tion may  be  limited 
by  stops,  if  desired. 

Having  summar- 
ized the  technic  of 
the  different  splint 
materials,  and  the 
principles  of  the  con- 
trol of  joint  motion, 
the  common  prob- 
lems presented  by  the 

major  joints  will  be  considered  in  order,  from  below 
upward. 


n 


w* 


UJ 

Fig.  225. — Snap  Joint. 


SPLINTING— SPECIAL 

Leg  Splints. — The  taesus  and  ankle  may  be  readily 
immobilized  by  a  plaster-of-Paris  splint  extending  from 
the  toes  to  the  top  of  the  calf.  Such  a  splint  is  usually 
applied  over  the  dressings  after  operations  on  the  foot. 


432  TECHNIC 

The  splint  may  be  made  removable  by  cutting  it  into  an 
anterior  and  posterior  gutter. 

After  the  mobilization  of  a  flat-foot  under  ether,  thtj- 
foot  is  put  up  in  extreme  adduction  and  inversion  so 
that  the  outer  border  looks  down  and  the  toes  point  in- 
ward. The  foot  must  be  well  padded,  especially  along 
the  outer  border,  and  strips  of  cotton  must  be  placed 
between  the  toes.  The  plaster  bandage  should  be  applied 
from  without  inward  across  the  sole,  and  the  splint  made 
thick,  especially  along  the  outer  border  of  the  foot;  it 
should  extend  to  below  the  knee. 

If  a  plaster  splint  is  not  to  be  walked  on,  it  may  be 
made  light,  and  may  be  worn  with  crutches  or  with  a 
Thomas  laiee  splint,  and  with  a  high  sole  on  the  well 
side.  A  wire  splint  following  the  back  of  the  leg  and 
sole  of  the  foot  and  connected  under  the  ball  and  behind 
the  calf  by  cross  wires,  is  a  very  serviceable  brace  for 
foot  and  ankle  fixation,  especially  when  there  are  dress- 
ings. Such  a  frame  is  bent  to  any  desired  angle,  covered 
with  bandage  leaving  out  the  heel,  padded,  and  bandaged 
to  the  foot  and  leg.  It  is  to  be  worn  in  bed  or  with 
crutches. 

Two-BAK  JoiNTLESS  Ankle  Splint. — For  long-contin- 
ued ankle  fixation  the  most  satisfactory  apparatus  is  the 
two-bar  ankle  splint  made  of  a  steel  bar  with  a  tongue 
forged  forward  at  the  middle;  this  is  riv^eted  by  three 
rivets  to  a  steel  foot  piece,  and  bent  up  on  either  side  to 
form  uprights;  the  uprights  are  connected  behind  the 
calf  by  a  steel  band  an  inch  or  more  wide;  the  side 
bars  are  yV  wide  and  8  gauge.  The  foot  piece  is  made 
from  15  to  16  gauge  sheet  steel  to  an  outline  of  the 


SPLINTING— SPECIAL 


433 


sole  on  paper,  and  may  be  made  somewhat  narrower  and 

shorter  than  the  outline  to  fit  inside  the  shoe.    The  calf 

band    and    sole    piece    are    lined 

with  leather,  which  is  riveted  in 

place,  and  the  splint  is  provided 

with  a  leather  heel  piece.     It  is 

kept  in  place  by  an  ankle  cross 

strap,  or  by  a  leather  lacing,  and 

by  a  strap  and  buckle  at  the  top 

(Fig.  201). 

Whitman  has  devised  a  very 
simple  and  ingenious  splint  to 
prevent  dorsal  flexion  of  the  foot 
(Fig.  226). 

Retention  and  supporting 

SPLINTS      FOR      the      AifKLE      oftcU 

must  be  worn  for  a  long  time, 
and  when  this  is  the  case  are 
usually  made  of  steel,  lined  with 
leather,  like  the  two-bar  fixation 
splint  just  described.  If  only 
lateral  support  is  required,  the 
splint  is  constructed  with  a  free 

lap  joint  in  each  bar  at  the  ankle ;  the  splint  works 
better  if  this  joint  is  placed  below  the  anatomical  ankle- 
joint  ;  two  inches  above  the  sole  plate  is  high  enough  for 
an  adult,  an  inch  and  a  half  for  a  child.  It  is  best  to 
make  all  steel  ankle  braces,  with  a  sole  plate  to  be  worn 
inside  a  laced  shoe.  Ankle  splints  made  with  the  two 
bars  jointed  to  a  U  piece  riveted  to  the  shank  of  the 
shoe,  while  sometimes  sufficient  for  light  support,  are 


Fig.  226.  —  Whitman's 
JoiNTLESs  Calcaneus 
Splint  with  Leather 
Sole,  Preventing  Dor- 
sal Flexion  of  the 
Foot. 


434  TECHNIC 

usually  unsatisfactory.  In  either  an  inside  or  outside 
brace  the  transverse  turn  of  the  U  piece  should  be 
brought  forward  two  inches  for  support  to  the  sole  plate, 
and  to  receive  an  anterior  rivet.  Better  still,  the  foot 
plate  of  the  inside  brace  should  be  forged  with  strong 
side  flanges,  to  be  pivoted  to  the  side  bars. 

When  motion  is  stopped  in  either  direction,  especially 
upward  or  in  both  directions  (limited  motion),  the  con- 
struction should  be  strong.  The  arrangement  of  stops 
which  should  be  placed  on  both  the  inside  and  outside 
bar  has  already  been  explained  (Fig.  224).  If  the  ankle 
falls  to  the  side,  lateral  support  is  needed.  If  the  ankle 
falls  inward  (valgus),  it  should  be  supported  on  the  in- 
ner side  by  a  T-shaped  or  other  ankle  strap,  buckling 
outside  the  outer  bar;  if  it  falls  to  the  outer  side,  the 
strap  should  be  placed  on  the  outer  side,  buckling  around 
the  inner  bar.  When  a  strong  pull  is  needed  the  counter 
pressure  may  be  taken  on  an  inner  or  outer  padded  side 
plate  or  flange.  The  foot  may  be  inverted  or  everted 
by  the  pull  of  the  ankle  strap,  and  the  action  may  be 
increased  by  bending  the  bars  laterally.  Flat  steel  bars 
may  be  bent  by  steel  hooks  such  as  those  shown  in  Fig. 
222,  or  by  adjustable  wrenches. 

CoERECTioN  Splints  for  the  Foot. — While  it  is  per- 
fectly feasible  to  correct  many  feet  deformities  with  ap- 
paratus, this  need  never  be  complicated.  Experience  has 
shown  that  severe  and  inveterate  cases  are  more  quickly 
and  perfectly  cured  by  forcible  stretching,  or  by  cutting 
contracted  tissues  under  an  anesthetic ;  when  this  is  done 
the  deformity  in  many  instances  recurs  unless  the  foot 
is  properly  held  by  a  suitable  appliance  for  a  sufficient 


SPLINTING— SPECIAL  435 

time.'  Infantile  cases  of  congenital  club-foot,  even  if  se- 
vere, may  usually  be  corrected  by  moderate  and  gradual 
manual  stretching  and  retention  with  adhesive  plaster 
or  in  a  splint  of  plaster-of-Paris  or  other  material,  re- 
newed or  straightened  from  week  to  week.  When  plas- 
ter-of-Paris is  used  the  foot  should  be  well  padded  with 
cotton  and  stretched  outward;  no  attempt  should  be 
made  to  correct  the  equinus  until  the  varus  is  overcome. 
It  is  often  well  to  run  the  plaster  up  above  the  slightly 
bent  knee,  and  to  apply  the  plaster  bandage  from  within 
outward  (across  the  sole),  and  pull  the  foot  out  by  pass- 
ing some  of  the  turns  directly  up  the  outer  side  of  the 
leg,  and  securing  them  by  circular  downward  turns. 
Mold  the  plaster  well  about  the  ankle  and  rotate  the 
foot  out  before  it  sets.  It  is  often  a  help  to  push  up  on 
the  sole  with  a  short,  thin  board,  to  give  the  splint  its 
final  shape.  Sometimes  in  fat  babies  the  splint  works 
down  on  the  foot  or  drops  off.  This  may  be  obviated 
by  attaching  adhesive  plaster  to  the  leg,  turning  the  end 
back  over  the  splint,  and  imbedding  it.  The  plaster 
should  be  changed  once  a  week;  this  is  better  than  cut- 
ting the  cast  and  gradually  correcting,  as  practiced  by 
"Wolff.  The  toes  should  be  watched  for  symptoms  of 
constriction.  The  same  result  may  be  obtained  by  ad- 
hesive-plaster strapping  in  the  light  cases,  or,  even  in 
severe  ones,  by  using  a  light  metal  splint  on  the  inner 
side  of  the  foot  and  leg,  which  is  at  first  bent  to  the 
deformity  and  afterwards  straightened  by  the  fingers 
as  the  deformity  yields.  This  principle,  laid  down  by 
C.  F.  Taylor,  is  embodied  in  the  simple  method  of  Jud- 
son,  who  used  a  small  brass  strip  with  a  stout  concave 


436 


TECHNIG 


band  at  each  end,  and  an  outer  band  which  is  strapped 
to  the  foot  by  adhesive  plaster  (Fig.  193). 

The  Taylor  one-bar  club-foot  splint,  now  usually  em 
ployed  as  a  retention  splint,  may  be  used  as  a  correction 
splint  (Fig.  195)  in  a  similar  manner.  It  may  be  asked 
why  not  always  make  one-bar  ankle  braces?  This  was 
C.  F.  Taylor's  practice,  the  bar  running  up  the  inner  side 
for  a  varus,  the  outer  for  a  valgus.    These  braces  were 


Fig.   227. — Varus  Brace  with  Inner   Side  Plate  or   Lip. 


provided  with  a  sole  plate,  a  side  plate  (or  lip)  (Fig.  227) 
for  counter  pressure,  a  down  stop  at  the  ankle,  and  spe- 
cial strapping,  and  gave  excellent  service.  They  take  up 
less  room  in  the  shoe  than  the  two-bar  splint,  and  are 
more  suitable  for  lateral  adjustment.  They  must  be 
made  stronger  and  are  more  expensive,  but  the  one  seri- 


SPLINTING— SPECIAL  437 

ous  objection  is  the  rapid  wear  of  the  joint  necessitating 
frequent  repair.  In  certain  cases,  however,  especially 
when  lateral  action  is  desired,  they  are,  if  well  made,  on 
the  whole  superior.  When  the  Taylor  club-foot  brace  is 
used  for  correction,  the  action  is  much  intensified  by 
holding  the  heel  to  the  splint  with  adhesive  plaster  and 
a  strap  and  buckle.  "With  a  suitable  splint  provided  with 
proper  strapping,  leverage  may  be  applied  up  to  the  tol- 
eration of  the  patient.  In  children  much  over  a  year  old, 
except  in  mild  cases,  the  division  of  the  heel  cord  and 
plantar  fascia  has  given  better  results  than  stretching 
in  the  hands  of  most  surgeons. 

Eotation  of  the  leg  cannot  be  entirely  controlled  at 
the  foot,  and  if  the  straightened  club-foot  continues  to 
point  inward,  as  not  infrequently  happens,  the  inside  bar 
retention  splint  should  be  attached  by  a  band  below  the 
knee  to  a  thigh  piece  and  pelvic  band,  having  free  joints 
at  the  knee  and  hip.  By  reason  of  the  grasp  on  the 
pelvis  exercised  by  the  pelvic  band,  the  foot  may  be  ro- 
tated outward  at  will  by  simply  twisting  the  side  bar 
(Fig.  196). 

Knee  splints  for  fixation  are  conveniently  made  of 
plaster;  the  splint  may  be  made  removable  by  cutting  it 
into  an  anterior  and  posterior  gutter,  which  may  be 
strapped  together  (Fig.  221).  Errors  to  be  avoided  are: 
too  loose  a  splint  and  too  short  a  splint  (Fig.  220). 
It  is  well  to  mold  the  splint  about  the  patella,  and  to  flat- 
ten it  behind  the  knee  to  ensure  stability  (Calot,  see  Fig. 
228).  It  is  often  well  to  include  the  foot,  which  gives 
better  fixation  and  prevents  swelling ;  it  is  not  often  nec- 
essary to  include  the  pelvis.    Adjustable  fixation  splints 


438  TECHNIC 

may  be  readily  and  cheaply  made  of  a  posterior  wire 
frame,  or  of  a  posterior  steel  bar  with  half  bands  at  the 
ends  (page  424),  provided  with  straps  and  buckles  or 


A  B 

Fig.    228. — A.  Plaster  Splint  Molded  About  Knee  to  Prevent  Rota- 
tion.    B.  Unmolded   Splint   Permits   Rotation.     (Calot.) 

bandaged  in  place.  Either  may  be  easily  bent  to  any  de- 
sired angle.  If  the  knee  is  nearly  straight  and  the  patient 
goes  about,  the  fixation  splint  should  include  the  foot. 
Such  splints  are  often  needed  for  use  on  one  or  both  legs, 
after  infantile  paralysis.  Two  side  bars  run  the  length 
of  the  leg,  ending  in  a  foot  plate,  as  in  the  two-bar  ankle 
brace,  and  having  a  wide  steel  band  behind  the  calf  and 
behind  the  upper  part  of  the  thigh;  the  outer  bar  should 
be  an  inch  or  more  longer  than  the  inner.  Leather  lining, 
straps,  and  a  broad  shaped  or  perforated  pad  over  the 
knee,  and  a  heel  band  complete  the  apparatus.  If  it  is 
desired  to  control  rotation,  as  often  happens,  the  outer 
bar  is  attached  to  a  steel  pelvic  band,  and  has  a  joint  at 
the  hip.  The  ankle  may  have  a  joint  suitable  to  its  needs, 
or  no  joint  if  it  is  desired  to  prevent  motion;  the  foot 
plate  fits  inside  the  shoe  (Fig.  229).  This  brace  is  sim- 
ple, cheap,  and  efficient;  its  main  disadvantage  is  the 
awkward  posture  in  sitting  with  straight  knees.  It  has, 
nevertheless,  enabled  many  helpless  patients  to  walk,  and 


SPLINTING— SPECIAL 


439 


hundreds  have  worn  it  for  years  without  noticeable  dis- 
comfort. 

When  in  chronic  disease  of  the  knee-joint  it  is  ad- 
visable to  combine  suspension  with  fixation,  the  Thomas 
knee  splint  is  the  most  practical  (Fig.  170).  This  consists 
in  two  3^  to  §  inch  steel  rods,  of  which  the  outer  is  about 


Fig.  229. — Steel  Fixation  Splints  for  the  Knee  with  Pelvic  Band  to 
Control  Rotation  at  the  Hip. 

three  inches  the  longer,  reaching  from  two  and  a  half  to 
three  inches  below  the  foot  to  the  groin  and  top  of  the 
trochanter  respectively.  It  is  well  to  lap  the  side  bars, 
and  join  them  by  screws,  to  provide  for  lengthening  the 


440  TECHNIC 

splint.  The  rods  are  inserted  below  into  a  cross  bar,  and 
brazed  to  a  y^g^-inch  steel  ring  above  at  an  angle  of  forty- 
five  degrees.  This  ring  is  somewhat  triangular,  with 
rounded  angles;  the  tuberosity  of  the  ischium  rests  on 
the  lower  side,  and  transmits  the  weight  of  the  body  to 
the  splint.  The  lower  end  is  shod  with  thick  leather 
or  rubber,  and  the  ring  is  padded  with  felt  and  covered 
with  smooth  leather.  The  splint  usually  carries  two 
short  straps  at  the  lower  end,  which  are  attached  to 
buckles  terminating  the  adhesive  plaster,  applied  to  the 
leg  below  the  knee.  These  plasters  carry  the  splint,  when 
the  splint  is  not  resting  on  the  ground,  and  may  be  used 
to  exert  traction.  If  adhesive  plaster  is  not  used,  as  in 
ankle  disease,  the  splint  is  suspended  from  the  shoulders 
by  webbing  suspenders  attached  to  the  front  and  back 
of  the  ring.  If  desired,  a  third  strap  may  be  attached 
to  the  back  of  the  lower  end,  which  is  fastened  to  a 
buckle  at  the  back  of  the  shoe  to  pull  the  heel  down, 
and  thus  keep  the  toes  off  the  ground.  The  Thomas 
brace  is  made  with  a  space  of  two  and  a  half  to  three 
inches  below  the  foot,  and  a  high  sole  to  correspond  is 
worn  on  the  foot  of  the  well  side.  The  ring  should  be 
an  inch  or  more  longer  than  the  inclined  circumference 
of  the  thigh  from  the  groin  to  above  the  trochanter.  The 
bars  are  provided  with  a  wide  leather  band  behind  the 
leg  and  thigh.  The  slipping  of  these  bands  may  be  pre- 
vented by  winding  half -inch  adhesive  plaster  around  the 
bar.  The  knee  is  kept  back  by  many  turns  of  a  bandage, 
or  by  a  fitted  pad  which  buckles  to  the  bars.  If  the  knee 
is  sore  it  is  sometimes  best  to  apply,  for  better  fixation, 
a  light  plaster-of-Paris  splint  to  the  knee,  to  be  worn 


SPLINTING— SPECIAL  441 

with  the  Thomas  splint;  but,  as  in  other  joints,  if  the 
process  is  very  acute,  it  is  best  to  put  the  patient  to 
bed  and  apply  weight  and  pulley  traction  for  a  few 
weeks  until  the  acute  symptoms  subside.  If  flexion  is 
not  great  the  Thomas  splint  may  be  used  to  correct  it; 
in  this  case  the  pressure  falls  on  the  back  of  the  ring, 
on  the  band  above  the  ankle,  and  on  the  front  of  the 
knee,  where  it  must  be  well  distributed.  Traction  often 
assists  correction  and  may  be  applied  in  bed,  or  by 
tightening  the  buckles  of  the  adhesive  plaster;  a  ratchet 
is  unnecessary. 

In  convalescent  cases  where  fixation  without  full  sus- 
pension is  desired,  the  so-called  caliper  splint  may  be 
used.  This  consists  in  the  Thomas  splint,  with  the  side 
bars  separate  below  and  the  ends  turned  inward.  These 
turned-in  ends  may  be  sprung  apart  like  a  caliper  and 
inserted  into  a  round  hole  bored  in  the  heel,  or,  better, 
into  a  metal  tube  fastened  to  the  sole  of  the  shoe  where  it 
joins  the  heel;  a  strap  above  the  ankle  keeps  the  ends 
from  springing  apart.  The  splint  is  made  the  length  of 
the  leg,  or  slightly  longer  if  it  is  desired  to  reduce  the 
joint  pressure. 

Correction  Splints  for  the  Knee. — When  it  is  de- 
sired to  change  the  posture  of  the  knee,  or  increase  the 
range  of  motion,  usually  in  extension,  this  may  be  done 
in  cases  suitable  for  brace  treatment  by  using  either  a 
plaster-of-Paris  or  metal  fixation  splint,  as  already  de- 
scribed, and  changing  the  angle  as  the  obstructing  tis- 
sues relax  (Fig.  230).  When  passive  motions,  massage, 
or  vibration  are  also  to  be  employed,  the  splint  must  be 
a  removable  one.    It  is  often  convenient,  instead  of  bend- 

30 


442 


TECHNIC 


ing  a  wire  or  bar,  to  have  a  splint  with  an  adjustable 
joint,  which  may  be  fixed  at  the  angle  of  choice.  Eecum- 
bency  and  traction  are  often  powerful  aids  to  correction, 
especially  in  inflammatory  conditions. 

The  correction  of  lateral  deformity,  especially  in  in- 
knee  and  out-knee,  is  a  very  common  problem  in  mechan- 


FiG.  230. — Correction  of  Knee  Flexion  by  Successive  Plaster  Splints. 

(Calot.) 


ical  orthopedics.  Only  the  younger  and  moderate  cases 
of  knock-knee  are  suitable  for  splint  correction.  Knock- 
knee  splints  with  a  movable  knee-joint  are  worthless, 
since  no  lateral  leverage  can  be  exerted  unless  the  knee 
is  held  straight.  Pressure  points  in  a  correcting  splint 
must  be  over  the  outer  side  of  the  upper  thigh  and  lower 
leg,  preferably  over  the  trochanter,  and  above  or  below 
the  ankle,  and  over  the  inner  side  of  the  knee.  The 
Thomas  knock-knee  splint  is  the  most  satisfactory  one  for 


SPLINTING— SPECIAL  443 

the  purpose  (Fig.  166).  This  consists  of  a  single  outer 
bar  reaching  from  the  trochanter  to  below  the  heel,  the 
last  two  inches  of  which  are  round  and  bent  at  a  right 
angle,  to  be  inserted  into  a  hole  in  the  heel  of  the  shoe  or 
into  a  tube,  as  in  the  caliper  splint.  The  splint  carries  a 
half  band  below  the  groin  and  above  the  ankle,  connected 
behind  the  leg  by  a  rigid  bar;  this  bar  is  usually  about 
half  the  length  of  the  outer  bar.  A  wide  leather  pad  is 
riveted  to  the  posterior  bar,  and  comes  around  the  inside 
of  the  knee  and  across  the  front,  to  be  fastened  by  three 
webbing  straps,  which  pass  around  the  outer  bar  and 
double  back  to  buckle  to  the  pad.  A  bandage  may  be 
used  instead  of  this  thin  pad.  There  is  a  small  steel 
plate  and  a  good  pad  over  the  trochanter,  and  in  order 
to  keep  them  in  place  and  control  the  rotation  of  the  leg 
at  the  hip,  it  has  been  found  advisable  to  attach  a  pelvic 
half  band  to  the  upper  end  of  the  bar ;  this  adds  greatly 
to  the  efficiency  of  the  splint.  This  pelvic  band,  like  all 
movable  pelvic  bands,  should  rest  at  the  level  of  the  an- 
terior superior  spines  of  the  ilium,  and  should  carry  a 
plate  two  inches  long  fixed  to  the  band,  and  pivoted  to 
the  end  of  the  side  bar  over  the  trochanter.  "Wlien  two 
splints  are  worn  the  two  half  bands  are  separated  by 
several  inches  in  front  and  behind,  which  are  closed  by 
a  strap  and  buckle.  The  adjustment  of  these  straps  con- 
trols rotation.  Children  generally  accustom  themselves 
to  the  stiffness  of  the  braces  and  walk  very  well;  they 
may  be  removed  at  night,  in  mild  cases.  In  out-knee, 
and  the  forms  of  bow-legs  that  involve  the  knee  or  thigh, 
stiff  splints,  with  outer  and  inner  bars  and  a  foot  piece  to 
go  inside  the  shoe,  may  be  used  in  young  children.    The 


444  TECHNIC 

splint  reaches  nearly  to  the  groin  on  the  inner  side,  and 
nearly  to  the  top  of  the  trochanter  on  the  outer,  and  is 
provided  with  a  long  leather  lacing  attached  to  the  inner 
bar,  and  reaching  from  above  the  ankle  nearly  to  the 
top ;  it  is  laced  inside  the  outer  bar,  and  draws  the  knee 
toward  the  inner  bar.  The  points  of  pressure  are  the 
inner  side  of  the  thigh  below  the  groin,  the  inner  side 
of  the  heel  and  leg,  and  the  outer  side  of  the  knee  and 
contiguous  parts.  For  bow-legs  below  the  knee  Knighfs 
hoiv-leg  splint  has  proven  itself  useful  in  suitable  cases 
(Fig.  176).  This  consists  of  a  two-bar  ankle  splint,  with 
a  free  joint  at  the  ankle,  whose  inner  bar  is  prolonged 
upward  one  and  a  half  inches,  and  carries  a  small  pad 
plate  and  a  pad,  bearing  on  the  internal  condyle;  a 
leather  lacing  is  attached  to  the  inner  bar ;  the  foot  part 
is  worn  inside  a  laced  shoe.  The  points  of  pressure  are 
the  inner  side  of  the  internal  condyle,  the  inner  side  of 
the  heel,  and  the  outer  side  of  the  leg.  This  is  not  a 
knee  splint,  but  is  mentioned  here  in  connection  with  the 
out-knee  splint  for  convenience. 

Knee  Splints  with  Joint  Motion  or  Adjustment. — 
A  knee  splint  on  the  plan  of  the  two-bar  supporting 
splint  with  foot  piece,  already  described,  may  be  made 
with  a  lap  joint  at  the  knee  on  both  sides.  If  the  joint 
is  to  have  free  motion,  this  should,  nevertheless,  al- 
ways be  stopped  when  the  two  bars  are  in  line  by  the 
conformation  of  the  joint  or  by  a  special  stop  or  flange, 
to  prevent  strain  on  the  posterior  ligament  of  the  knee 
and  hyperextension  (Fig.  231).  It  is  often  well  to  rivet 
a  disc  to  the  inner  side  of  the  outer  bar,  having  the 
joint  pivot  as  a  center.    If  this  disc  is  riveted  to  the 


SPLJN^riNG— SPECIAL 


445 


upper  bar,  and  also  to  the  lower,  the  joint  will  be  fixed; 
but  if  a  row  of  screw  holes  be  made  in  the  disc  the  angle 
may  be  changed  by  changing  the  screw  from  one  hole 
to  another. 


Fig.  231. — Jointed  Knee  Splint  with  Stop  to  Prevent  Hyperextension. 
The  splint  at  the  right  has  a  disc  for  controlling  motion. 

Motion  may  be  limited  by  placing  stops  on  the  disc, 
and  this  motion  may  be  shifted  to  any  point  by  shifting 
the  disc  at  the  upper  bar.  A  snap  joint  may  be  used  as 
already  described  (Fig.  225),  to  give  a  stiff  joint  when 
standing,  and  allow  the  knee  to  bend  when  the  patient  is 


446  TECHNIC 

seated.  A  one-bar  knee  brace  with  a  long  outer  bar  may- 
be used,  to  which  a  short  inner  bar,  with  curved  plate 
above  the  knee,  is  joined  by  two  curved  cross  bars  in 
front  of  the  thigh,  above  the  knee  and  below  the  groin. 
This  makes  a  very  elegant  and  efficient  brace,  but  is  ex- 
pensive and  difficult  to  make.  The  joint  and  outer  bar 
must,  of  course,  be  made  much  stronger  than  in  the  one- 
bar  apparatus. 

In  all  leg  braces  it  is  well  to  make  the  side  bars  either 
above  or  below  the  knee,  or  both,  of  two  overlapping 
pieces,  screwed  together  to  allow  for  adjustment  and 
growth.  Ejiee  splints  are  sometimes  made  with  a  slip- 
joint  at  the  ankle,  in  order  that  the  shoe  may  be  removed 
at  night  without  removing  the  splint  (Fig.  224,  G). 

FixATioisr  Hip  Splints. — The  most  practical  fixation 
hip  splint  is  undoubtedly  the  long  plaster-of-Paris  sj^ica, 
reaching  from  the  toes  to  the  nipples;  the  posture  of 
choice  should  be  given  to  the  hip,  usually  extension  and 
slight  abduction,  and  if,  before  the  plaster  is  set,  the 
knee  is  slightly  flexed,  it  will  add  greatly  to  the  patient's 
comfort.  While  foot  and  knee  plasters  are  easily  ap- 
plied, the  hip  spica  requires  some  little  skill.  The  spica 
may  be  applied  with  the  patient  suspended  from  the 
head,  but  is  usually  put  on  with  the  patient  recumbent. 
In  this  case  the  patient  should  be  supported  on  a  hip  and 
shoulder  rest.  A  tomato  can  padded  with  cotton  makes 
a  serviceable  hip  rest  in  an  emergency,  while  the  back 
and  shoulders  may  be  supported  on  a  low  box  or  one  or 
two  folded  pillows.  An  adjustable  hip  and  shoulder  rest 
is  in  use  at  the  Hospital  for  the  Euptured  and  Crippled, 
as  shown  in  the  cut  (Fig.  232),  and  Gallie  has  devised  a 


SPLINTING— SPECIAL  447 

suit  case  rest  on  the  same  principle  (Fig.  233),  with  the 
additional  advantage  that  the  case  contains  the  hip  rest, 
bandages  and  accessories  when  not  in  use,  and  is  port- 


FiG.  232. — Adjustable  Hip  and  Shoulder  Rest  Used  at  the  Ho-spital 
FOR  Ruptured  and  Crippled. 

able.  There  are  many  other  good  hip  rests ;  Schultze's 
(Fig.  222,  C),  with  closing  blades  to  facilitate  removal 
when  the  spica  is  finished,  being  large  and  strong,  is 


Fig.  233.— Suit  Case  Hip  and  Shoulder  Rest.     (Gallie.) 

particularly  good  for  adults  and  after  operations.  With 
all  these  rests,  two  assistants  are  needed  to  hold  the  legs 
and  steady  the  patient,  and  several  apparatus  have  been 


448 


TECHNIC 


devised  to  hold  the  leg,  with  or  without  traction  in  the 
posture  of  choice,  in  addition  to  supporting  the  pelvis 


Fig.  234. — Portable  Hip  and  Shoulder  Rest  and  Extension  Apparatus. 

(Sanderson.) 

and  shoulders.  Sanderson's  portable  machine  (Fig.  234) 
seems  to  be  a  very  good  model. 

The  Echols  traction  apparatus  "  was  designed  pri- 
marily for  the  treatment  of  fractures  of  the  femur  by 
means  of  the  spica  plaster-of -Paris  (ambulatory)  cast, 
but  it  is  exceedingly  useful  for  a  variety  of  other  sur- 
gical and  orthopedic  purposes,  chief  of  which  are  the 
following : 

"  1.  All  open  operations  on  the  femur  where  traction 
and  fixation  of  the  limbs  during  operation  is  desirable, 
such  as  operations  for  ununited  fracture,  osteotomia  sub- 
trochanterica,  etc. 

"  2.  Application  of  a  sj^ica  cast  immediately  following 
such  operations;  the  apparatus  permits  the  operator  to 


SPLINTING— SPECIAL  449 

vary  the  adduction,  abduction,  flexion,  etc.,  of  the  limbs 
without  releasing-  the  traction  or  disturbing  the  position 
of  the  patient. 

"  3.  Breaking  up  old  tuberculous  ankylosis  of  the  hip- 
joint  in  cases  where  there  is  lordosis  with  flexion  and 
adduction. 

.  "  4.  By  using  a  suitably  improvised  back  and  shoul- 
der support  the  apparatus  lends  itself  admirably  to  the 
application  of  body  casts  for  Pott's  disease. 

"  5.  From  a  study  of  the  accompanying  illustrations 
it  will  be  seen  that  by  inverting  the  apparatus  the  same 
traction  may  be  applied  to  the  legs  without  lifting  the 
patient  from  the  bed — a  procedure  which  may  be  useful 
in  applying  a  Liston  splint. 

"  As  the  figures  indicate,  the  apparatus  when  in  use 
is  merely  laid  on  a  table,  but  is  not  attached  to  it  in  any 
way — an  obvious  advantage  in  many  cases. 


Fig.  235. — Hip  Rest  and  Traction  Appliance.     (Echols.) 

"  Fig.  235  shows  two  long  horizontal  leg  bars,  each 
forty-two  inches  in  length,  a  vertical  perineal  post  twelve 
inches  in  height,  and  two  vertical  foot  posts  of  the  same 
height — all  made  of  drawn  seamless  steel  tubing  one  and 


450 


TECHNIC 


one  eighth  inches  in  diameter,  comparatively  light,  and 
practically  unbreakable. 

"  The  perineal  post  is  supplied  with  a  thin,  strong 
sacral  plate  which  is  adjustable  at  any  height.  A  leather- 
covered  hollow  cylinder  of  wood  can  be  slipped  over  the 
perineal  post  to  give  a  broader  surface  for  pressure  in 
cases  where  strong  traction  is  wanted. 

"  The  horizontal  leg  bars  can  be  opened,  compasslike, 
to  any  desired  degree  of  abduction  up  to  180  degrees  and 
securely  locked  in  any  position  by  means  of  a  set-screw 
clamj). 

"  Two  sliding  and  telescoping  crutches  are  attached  to 
the  horizontal  leg  bars  by  means  of  split  clamps,  and  are 
adjustable  in  a  great  variety  of  positions. 

"  A  specially  designed  sole  plate  equipped  with  a 
double  pulley  is  attached  to  each  of  the  patient's  feet 
by  means  of  a  common  muslin  bandage. 


Fig.  236. — Hip  Rest  and  Traction  Appliance  in  Use.     (Echols.) 

"  On  each  of  the  vertical  foot  posts  is  an  original 
tackle  block  and  clamping  device,  adjustable  at  any 
height.    Traction  is  made  as  indicated  in  Fig.  236.    The 


SPLINTING— SPECIAL 


451 


pull  made  by  the  operator  is  multiplied  by  4.  For  exam- 
ple, a  pull  of  100  pounds  on  the  cord  produces  a  traction 
of  approximately  400  pounds  on  the  foot.  When  the 
operator  stops  pulling,  the  automatic  clamp  pinches  the 
cord  firmly  and  prevents  any  release  of  traction. 

"  Hyperextension  or  moderate  flexion  of  the  hip-joint 
may  be  produced  by  (a)  raising  or  lowering  the  sacral 
plate,  (b)  raising  or  lowering  the  clamping  device  on  the 
vertical  foot  posts,  and  (c)  varying  the  thickness  of  the 
improvised  head  and  shoulder  rest. 

"  The  castings  are  all  made  of  tough  malleable  iron. 
The  entire  apparatus  is  nickel  plated.    It  can  be  quickly 


Fig.  237. — Ducroqxjet's  Machine. 


dissembled,  and  is  carried  like  a  shotgun  in  a  canvas  bag. 
It  weighs  about  twenty-five  pounds,  and  will  tolerate  a 
strain  of  at  least  600  pounds  traction."     (Echols.) 

The  elaborate  appliance  of  Ducroquet  (Fig.  237)  com- 
bines a  hip  and  shoulder  rest  with  means  for  controlling 
rotation  and  flexion  of  the  legs  as  well  as  lateral  motion. 
It  is  especially  useful  for  holding  the  patient  in  the  vari- 


452 


TECHNIC 


ous  postures  necessary  after  the  reduction  of  congenital 

dislocation  of  the  hip,  and  in  overcoming  thigh  adduction 

after  coxitis. 

The  long    spica,   applied   during   traction   and  well 

molded  to  the  knee  and  limb,  undoubtedly  diminishes 

pressure  on  the  joint 
during  locomotion, 
which  is  nevertheless 
to  be  avoided  during 
the  acute  stage.  It 
should  be  strength- 
ened in  front  of  and 
behind  the  hip  and 
behind  the  knee. 

The  long  plaster 
spica  has  been  abbre- 
viated at  both  ends, 
but  then  gives  less 
fixation.  Calot  molds 
it  carefully  to  the  pel- 
vis and  ends  it  near 
the  waist.  Others  ter- 
minate it  above  the 
ankle  or  at  the  knee. 
Such  spicas  answer 
certain  indications 
very  well,  especially 
those    in    the    treat- 

FiG.    238.  — Short    Plaster    Spica    for  ment      of      congenital 

Fixation  at  the  Hip;   the  Fixation  ^-          l^^ation       after 

IS  Better  if  the  Spica  is  Prolonged  ^ 

Upward  Nearly  to  the  Nipples.  replacement.         They 


SPLINTING— SPECIAL 


453 


should  be  thickly  padded,  as.  they  are  made  thick  about 
the  pelvis  and  are  subjected  to  a  good  deal  of  strain; 
they  often  remain  three  months  or  more  without  change. 


Fig.  239. — Thomas's  Hip  Splints,  Single  and  Double. 

The  edges  should  be  wet  and  rubbed  after  trimming,  to 
round  off  the  inner  margins  and  to  seal  the  plaster.  The 
short  spica  may  be  covered  with  the  surplus  of  the  stock- 
inette over  which  it  is  applied,  or  with  a  muslin  spica 


454  TECHNIC 

to  keep  it  clean.  The  short  spica  from  the  knee  to  the 
umbilicus  is  much  used  in  the  convalescent  stage  of  hip 
disease  (Fig.  238). 

Another  form  of  fixation  splint  is  the  Thomas  hip 
splint  (Fig.  239),  consisting  of  a  strong  posterior  steel 
bar  from  the  axillary  level  to  above  the  ankle.  This  bar 
is  shaped  to  the  buttock,  and  is  provided  with  steel  bands 
at  the  bottom,  top,  and  also  below  the  crotch.  It  is 
suspended  from  the  shoulders,  and  secured  to  the  trunk 
and  hip  by  bandages.  If  the  thigh  has  a  tendency  to 
flexion,  the  points  of  pressure  are  in  front  of  thorax, 
behind  hip,  and  in  front  of  leg.  This  splint  is  to  be  used 
during  recumbency  or  with  crutches;  it  may  be  applied 
when  the  thigh  is  flexed  and  gradually  straightened,  thus 
acting  as  a  correction  splint. 

Suspension  and  Traction  Hip  Splints. — Most  Amer- 
ican surgeons  have  preferred  for  a  traction  splint  the 
Taylor  hip  splint,  or  some  of  its  modifications.  This 
splint  is  not  directly  a  fixation  splint,  but  a  suspension 
splint  with  traction.  Its  simplest  form  consists  in  a 
rigid  pelvic  band  and  a  rigid  outer  bar  reaching  from 
the  hip  band  to  two  inches  below  the  foot.  This  outer 
bar  consists  in  a  lower  part  notched  for  a  ratchet,  and 
playing  in  the  tubular  upper  part.  The  lower  end  of  the 
splint  is  turned  under  the  foot  and  is  attached  by  straps 
to  buckles  on  the  adhesive  plaster;  the  hip  band  carries 
two  perineal  straps;  the  side  bar  is  firmly  clamped  or 
riveted  to  the  hip  band  (not  jointed),  and  has  a  steel  band 
behind  the  knee  carrying  a  strap.  When  the  ratchet  is 
screwed  out  by  a  key  the  splint  is  lengthened,  and  may 
be  fixed  by  a  stop  at  any  point ;  if  the  adhesive  and  peri- 


SPLINTING— SPECIAL  455 

neal  buckles  are  fastened,  the  ]eg  is  pulled  (traction). 
When  used  as  an  ambulant  splint,  a  cork  sole  is  to  be 
worn  on  the  well  foot. 

This  splint  has  been  much  misunderstood,  but  has 
rendered  good  service.  It  affords  only  indirect  and  par- 
tial fixation  by  the  brake  action  of  the  perineal  straps, 
and  has  projDcrly  been  supplemented  by  the  addition  of 
a  thoracic  band  joined  to  the  pelvic  band  by  a  rigid 
upright  bar  at  the  side,  and  simplified  by  the  elimination 
of  the  ratchet,  as  in  the  so-called  Polyclinic  hip  splint 
(Fig.  153),  a  very  simple  and  efficient  appliance.  The 
upright  is  forged  from  iV  to  f  inch  steel,  clamped  to 
the  band  by  a  nut  and  screw  with  square  shank.  The 
band  is  made  of  bar  steel  |  to  y\  inch  thick  and  1  to  1^ 
inch  wide.  This  is  a  fixation  and  suspension  splint  for 
the  hip,  furnishing  so  much  traction  as  may  be  obtained 
by  tightening  the  adhesive-plaster  buckles.  This,  how- 
ever, may  be  done  to  the  limit  of  the  patient's  endurance ; 
the  ratchet  can  do  no  more.  The  ratchet,  however,  is 
convenient  for  adjustment,  but  this  can  be  readily  ob- 
tained by  making  the  splint  of  two  overlapping  forged 
bars  screwed  together. 

Phelps  has  given  precision  to  the  action  of  the  splint 
by  dropping  the  perineal  straps,  which  are  difficult  to 
keep  clean,  and  too  readily  loosened,  and  replacing  them 
by  a  wire  ring  borrowed  from  the  Thomas  knee  splint. 
He  thought  also  to  add  lateral  traction,  but  this  was 
really  unnecessary,  and  was  finally  reduced  to  a  band 
above  the  knee,  whose  only  function  is  to  steady  the  leg. 
The  simple  form  of  the  Phelps  hip  splint  (Fig.  152)  with- 
out a  ratchet,  to  be  used  with  crutches  and  a  high  shoe 


456  TECHNIC 

on  the  well  side,  is,  perhaps,  all  things  considered,  the 
most  satisfactory  form  of  hip  splint  for  ordinary  use  in 


Ht 

Fig.  240.  —  Plaster  Spica  Ending  Fig.  241.  —  Gallie's   Hip  Splint 

Above  Shoe,  Prolonged  to  Floor  for  Traction  in  Bed.      (Starr 

BY  A  Rigid  U-Shaped  Steel  Bar,  and  Gallie.) 
Suspending  Leg.     (Lorenz.) 

hip  tuberculosis.  If  a  plaster  spica,  reaching  to  below 
the  calf,  is  carefully  molded  to  the  pelvis  and  perineum, 
and  prolonged  under  the  foot  by  a  bent  steel  bar,  as  is 


SPLINTING— SPECIAL  457 

done  in  Vienna,  a  similar  effect  is  produced  (Fig.  240). 
No  splint  is  capable  of  filling  the  indications  in  all  cases 
or  in  all  stages;  the  stage  of  acute  symptoms  is  best 
treated  by  recumbency  with  traction  in  bed  (Figs.  151 
and  241),  and  the  stage  of  convalescence  by  splints  which 
permit  partial  use  of  the  limb. 

Pelvic  Splints. — The  pelvis  serves  as  a  base  for  spinal 
splints,  and  transmits  the  body  weight  to  suspension 
splints.  It  also  serves  by  fixing  the  position  of  a  pelvic 
band  to  control  the  direction  of  the  foot  (hip  rotation). 

The  splinting  which  the  pelvis  itself  requires  is 
mainly  that  of  circular  support  by  a  snug  enveloping 
band,  adjusted  above  the  trochanters  to  relieve  the  sacro- 
iliac joints  of  strain.  This  may  be  done  by  a  circular 
bandage  with  short  double  spica,  by  strapping  with  four 
strips  of  two-inch  zinc-oxid  plaster,  pulled  tight,  and  in- 
terrupted for  a  few  inches  in  front  (Fig.  128) ;  by  a 
three-inch  surcingle  and  buckle,  which  may  be  attached 
to  the  lower  end  of  a  long  corset;  by  a  wide  plaster-of- 
Paris  belt,  secured  by  perineal  straps  (Fig.  242).  When 
it  is  necessary  to  control  the  tilt  of  the  sacrum,  or  to 
support  the  spine  in  addition  to  the  circular  compres- 
sion, a  plaster-of-Paris  corset  or  jacket  should  be  ap- 
plied, which  must  come  well  down  over  the  hips  and  be 
snugly  adjusted  to  the  pelvis.  A  long  woman's  corset, 
strengthened  with  side  and  back  steels  and  provided  with 
surcingle  and  buckles  below,  answers  admirably  in  some 
cases. 

Arm  Splints. — As  the  arm  is  naturally  pendant  and 
does  not  bear  weight,  the  appliances  for  controlling  it 
are  much  simpler  than  those  for  the  leg. 

31 


458 


TECHNIC 


The  fingers  may  be  fixed  by  binding  with  adhe- 
sive plaster,  stiffened  with  small  splin+s  of  wood  or 
whalebone,    or    by    small    aluminium    splints    with    Ox 


Fig.   242. — Plaster-of-Paris  Band  with  Perineal  Straps  for  Pelvic 
Support.     The  patient  is  recovering  from  tuberculosis  of  the  pelvis. 

without  flanges.  If  the  metacarpo-phalangeal  joint  is 
to  be  controlled  the  splint  must  include  the  palm 
(metacarpus).     If   the   fingers    are   to   be   flexed   they 


SPLINTING— SPECIAL 


459 


may  be  bandaged   over   a   roll    of   Imndage   or  a  ball 
of  yarn. 

The  wrist,  forearm,  elbow,  and  ui)per  arm  are  pretty 
readily  fixed  in  the  pos- 
ture of  clioice  by  plas- 
ter-of-Paris  splints  of 
either  the  tubular  or 
gutter  type. 

Padded  wire  splints, 
and  bar  and  band  splints, 
may  be  used  for  the  el- 
bow, as  at  the  knee.  A 
wrist  splint  should  in- 
clude the  hand,  and 
often  the  fingers,  and 
may  consist  of  alumin- 
ium or  other  thin  metal 
applied  to  the  palmar 
surface,  and  bent  up  at 
the  wrist.  It  may  be. 
bandaged    in    place,    or 

secured  by  straps  below  the  elbow,  over  the  wrist  and 
metacarpus  (Figs.  122  and  243). 

The  shoulder  and  elbow  may  also  be  relatively  immo- 
bilized by  the  neck  halter,  a  simple  and  ingenious  device 
of  Thomas,  by  carrying  the  arm  in  a  sling  or  by  pinning 
the  sleeve  to  the  top  of  the  jacket  by  a  safety  pin  (Fig. 
111).  If  it  is  desired  to  immobilize  the  shoulder  with 
the  arm  abducted,  a  shoulder  cap  or  spica  of  plaster 
encircling  the  upper  thorax  may  be  used  (Fig.  117). 

The  elbow  may  be  kept  in  acute  flexion  by  strap- 


FiG.    243. 


Splint    for    Wrist    and 
Hand. 


460  TECHNIC 

ping  the  forearm  against  the  upper  arm  with  adhesive 
plaster. 

Spinal  Splints,  Frames,  Jackets,  Corsets,  and  Braces. — Effi- 
cient spinal  appliances  give  lateral  as  well  as  anterior 
and  posterior  support.  They  are  practically  all  fixation 
splints,  no  matter  what  their  construction,  as  will  appear 
after  a  complete  study  of  their  mechanical  effect.  The 
only  real  spinal  traction  is  by  head  suspension,  which 
cannot  be  long  maintained,  or  by  weight  and  pulley  or 
frame  traction  in  recumbency. 

The  different  so-called  suspension  and  traction  ap- 
pliances are  merely  different  ways  of  applying  leverage 
to  the  spine,  and  they  are  efficient  in  proportion  as  they 
do  actually  fulfill  the  conditions  of  an  effective  lever. 
It  has  been  thought  by  some  that  recumbency  alone 
would  relieve  the  sore  or  weakened  spine  of  superin- 
cumbent weight,  and  thus  furnish  relief.  This  method 
has  been  extensively  tried  with  poor  results,  and  it  is 
easy  to  see  that  an  ordinary  bed  could  hardly  furnish 
the  necessary  conditions  for  efiicient  fixation,  even  if  the 
patient  could  lie  without  moving,  which  is  impossible. 
While  periods  of  recumbency  are  indispensable  in  the 
acute  stage  of  spinal  disease,  they  must  be  supplemented 
by  definite  mechanical  support  to  the  spine. 

Anteko-posteeior  Spiital  Splints.  —  The  Whitman 
frame  is  the  simplest  and  most  practical  of  all  the  gut- 
ters, cuirasses,  plaster-of -Paris  beds,  and  similar  appli- 
ances to  enforce  recumbency  and  at  the  same  time  give 
definite  spinal  support.  It  is  the  appliance  of  choice  in 
the  early  stages,  and  may  be  used  for  a  year  or  more 
in  children  under  three,   and  even  for  older  children, 


SPLiNTlNG— SPECIAL 


461 


suffering  from  ])otli  hip  and  spinal  disease,  bilateral  hip 
disease,  or  multiple  joint  involvement.  A  wire  frame 
was  used  by  Bradford  many  years  ago,  but  has  been  so 
radically  modified  by  Whitman  as  to  require  a  different 
name.     The  Whitman  frame  is  an  elongated  quadrilat- 


FiG.  244. — Whitman  Frame  Uncovered  at  Right,  Bandaged  at  Left; 
Canvas  Cover  Showing  Pads  and  Apron  in  IMiddle. 

eral  of  quarter-inch  (caliber)  gas  pipe,  made  a  foot 
longer  than  the  recumbent  patient,  and  as  wide  as  the 
distance  between  the  outer  sides  of  the  anterior  superior 


462  TECHNIC 

iliac  spines.  A  child  a  year  old  takes  a  frame  five  inches 
wide.  The  frame  is  covered  with  black  enamel,  to  pre- 
vent rusting,  and  a  canvas  cover  is  made  for  it,  which 
wraps  around  it  and  is  laced  up  tight  behind.  The  frame 
should  be  bandaged  before  the  canvas  is  applied.  The 
part  of  the  canvas  under  the  child's  buttocks  and  thighs 
is  covered  with  rubber  cloth.  The  position  of  the  kyphos 
is  marked  on  the  canvas,  and  two  thick  felt  pads  six  or 
eight  inches  long  are  sewed  to  the  canvas  near  together 
opposite  this  point,  to  give  definite  pressure  over  the 
laminae  of  the  affected  region,  as  do  the  pads  of  a  spinal 
splint  (Fig.  244).  The  ujDper  part  of  the  frame  is  then 
bent  back,  over  the  edge  of  the  table,  at  the  point  of  the 


Fig.  245. — Whitman  Frame  with  Head  Traction.  This  patient  is  making 
a  good  recovery  from  tuberculosis  of  the  spine,  hip,  and  wrist  tendons. 
(Albee.) 

projection,  to  allow  the  head  to  drop  back  and  to  in- 
crease the  leverage.  If  the  disease  is  high  up,  a  T  is 
added  at  the  upper  end,  to  which  a  head  halter  is  at- 
tached (Figs.  95  and  245) ;  traction  may  be  increased  by 
adding  T  pieces  at  the  foot  of  the  frame  and  attaching 
their  straps  to  adhesive  plasters  on  the  leg ;  this  is  espe- 
cially indicated  in  the  hip  cases.    The  child  is  fastened 


SPLINTING— SPECIAL  463 

to  the  frame  by  a  canvas  apron  strapped  to  buckles  at 
the  back  of  the  frame,  where  they  cannot  be  readied  l)y 
the  child.  The  child  may  be  carefully  rolled  off  the 
frame  once  a  day  and  the  back  rubbed  with  alcohol  and 
powdered;  it  should  never  sit  u]).  The  clothes  may  be 
put  on  the  child  fastening  behind,  and  including  the 
frame,  and  the  child  may  be  carried  about  on  the  frame, 
which  may  also  be  placed  on  a  long  peraml)ulator.  Chil- 
dren may  be  kept  a  year  or  longer  on  such  a  frame  with 
marked  benefit,  if  properly  cared  for.  The  ribs  and  tis- 
sues flatten  out  behind  after  long  confimement  on  a 
frame,  giving  the  back  a  flat  appearance. 

The  plaster-of-Paris  jacket,  properly  applied,  is  an 
invaluable  splint,  especially  in  hospital  and  dispensary 
practice;  it  needs  to  be  supplemented  with  recumbency 
in  the  acute  stages  of  the  disease.  The  term  "  jacket " 
is  used  here  to  indicate  a  fixed  splint,  the  word  "  corset " 
being  reserved  for  removable  splints  of  whatever  mate- 
rial. A  fixed  jacket  is  always  worn  until  the  patient  is 
convalescent — a  matter  of  years. 

The  problem  of  splinting  the  spine  is  a  difficult  one; 
jackets  should  be  long,  strong,  and  snug,  and  applied  in 
proper  posture.  Jackets  as  usually  applied  by  the  in- 
expert are  inefficient;  they  make  the  back  sore  or  get 
soft,  or  the  patient  slowly  doubles  up  inside  of  them. 
The  plaster  jacket  may  be  applied  either  in  the  vertical 
or  horizontal  posture.  The  vertical  posture  is  the  one 
in  common  use,  and  on  the  whole  gives  the  best  results. 
The  jacket  is  applied  with  the  body  wholly  or  partly 
suspended  from  the  head  by  a  head  halter  and  traction 
pulleys.     The  compound  pulleys  may  be  attached  to  a 


464  TECHNIC 

hook  screwed  over  a  doorway  or  into  an  overhead  beam. 
The  conventional  trijDod  has  always  seemed  to  the  writer 
an  extremely  clumsy  and  superfluous  contrivance.  All 
that  is  needed  is  a  strong  screw  hook,  compound  pulleys 
and  cord,  a  cross-piece  of  wood,  and  a  bandage.  For 
office  or  hospital  use,  where  no  beam  is  at  hand,  a  pro- 
jecting bracket  is  far  better  than  a  tripod,  and  for  a 
portable  appliance  AVilson's  adjustable  bracket,  which 
separates  into  three  small  pieces,  is  more  convenient,  as 
it  is  light  and  can  be  carried  in  a  suit  case,  and  can  be 
adjusted  to  the  top  of  a  door  without  screws.  A  stick 
of  wood  with  screw  rings  in  the  middle  and  at  each  end, 
and  a  bandage  take  the  place  of  the  cross-piece  and  head 
sling  (Fig.  246).  The  patient  is  covered  with  a  thin, 
sleeveless  undershirt,  or  stockinette  tubing  twice  as  long 
as  the  jacket ;  this  is  tied  together  with  a  bit  of  bandage 
over  the  shoulders.  It  is  well  to  hang  strips  of  silent 
cloth  four  or  five  inches  wide  down  the  front,  back,  and 
sides,  to  prevent  chafing;  they  may  be  suspended  by 
folding  the  ends  under  the  upper  edge  of  the  stockinette. 
It  is  also  important  to  apjDly  thick  felt  pads  six  or  eight 
inches  along  either  side  of  the  kyphos.  If  a  dinner  pad 
is  desired,  a  towel  folded  zigzag  may  be  placed  over  the 
epigastrium,  with  an  end  projecting  below,  for  removal. 
The  dinner  pad  is  not  much  used  at  the  Hospital  for  the 
Euptured  and  Crippled.  In  women  the  breasts  should 
be  protected  by  a  compress  of  cotton.  The  patient 
stretches  the  arms  up  and  grasps  the  cross-piece  or  band- 
age, and  is  carefully  drawn  up  by  the  pulley  cord  until 
only  the  toes  rest  on  the  ground ;  the  cord  is  fastened  so 
that  it  can  be  quickly  released,  or  given  to  an  assistant 


SPLINTING— SPECIAL 


465 


to  hold.  The  operator,  seated  behind  the  patient,  draws 
the  patient's  legs  slightly  back  and  steadies  them  be- 
tween his  knees.  An  assistant,  seated  in  front,  is  desir- 
able but  not  essential.    Plaster  bandages  five  inches  wide 


Fig.  246. — Suspension  froiM  Wilson's  Adjust.\ble  Bracket,  by  Wooden 
Cros.s-Piece  and  Bandage. 

and  six  yards  long  are  thoroughly  soaked  in  a  pail  of 
tepid  water,  and  applied  pretty  wet.  The  operator  may 
begin  below  and  include  the  pelvis,  first  bringing  the 


466  TECHNIC 

plaster  as  low  as  the  pubes  in  front  and  to  the  commis- 
sure of  the  nates  behind.  By  spiral  and  crisscross  turns 
the  jacket  is  applied  to  the  torso,  turning  in  darts  where 
there  is  superfluous  bandage,  and  rubbing  the  turns  as 
they  are  applied.  The  jacket  is  gradually  prolonged 
upward,  bringing  it  up  to  the  episternal  notch  in  front 
and  to  the  base  of  the  neck  behind.  Barnett,  at  the 
Hospital  for  the  Ruptured  and  Crippled,  prefers  to  ap- 
ply the  bandages  from  the  top  downward,  and  gets  ex- 
cellent results.  The  jacket  must  be  made  thick  at  the 
upper  and  lower  edges.  Before  it  is  set  it  is  well 
molded  over  the  trochanters  and  iliac  crests,  as  it  is 
essential  that  the  jacket  have  a  firm  grip  on  the  pelvis 
to  furnish  a  stable  base.  After  it  is  finished  and  well 
rubbed  down  it  is  trimmed  above  and  below,  and  well 
hollowed  below  the  axillse,  and  over  the  groins  to  permit 
sitting.  The  stockinette,  which  has  been  left  long,  is 
then  drawn  up  and  stitched  to  its  upper  border  to  make 
a  covering  for  the  jacket.  In  ten  minutes  the  jacket  is 
sufficiently  dry  to  hold  its  shape  when  the  patient  is  let 
down;  it  will  not  be  thoroughly  dry  until  the  next  day. 
A  jacket  for  a  small  child  takes  four  bandages  of  the 
size  mentioned,  and  weighs  a  pound  and  a  half.  For 
an  adult  seven  or  eight  bandages  are  needed.  The  jacket 
may  also  be  applied  with  the  patient  lying  face  do'wn  on 
a  sling  or  hammock,  niade  of  muslin.  A  strip  of  muslin 
two  and  a  half  yards  long  is  split  into  five  tails  at  each 
end,  and  the  two  outer  tails  at  each  corner  tied  to  the 
two  chairs  placed  back  to  back  two  yards  apart.  The 
chairs  must  be  secured  to  a  plank  passed  over  the  rounds, 
or  an  adult  may  sit  on  each  chair.    The  patient  is  pre- 


SPLINTING— SPECIAL 


467 


pared  in  the  usual  way,  and  is  placed  face  down  on  the 
sling,  the  hands  stretched  upward  and  grasping  the  edge 
of  the  hammock.  The  plaster  is  then  applied  in  the  usual 
way,  and  the  muslin  may  be  cut  off  and  drawn  out,  when 
the  jacket  is  finished. 

If  the  usual  cross-piece  carrying  the  head  halter  is 
fastened  to  a  hook  three  feet  from  the  floor,  and  the 
patient's  feet  are  grasped 
by  an  assistant,  holding  the 
child  in  the  horizontal  pos- 
ture, the  effect  is  the  same. 
There  is  a  large  number  of 
frames,  rests,  and  other  de- 
vices for  supporting  the  pa- 
tient in  the  prone  or  supine 
posture,  but  they  are  not 
essential. 

The  conventional  jacket, 
as  described,  does  not  give 
efficient  support  above  the 
ninth  dorsal  vertebra,  and 
when  the  disease  is  above 
this  point  the  leverage  must 
be  prolonged  upward.  This 
is  usually  done  by  adding  a 
jury  mast  and  sling  for  head 
support,  and  to  pull  the 
head    backward     (Figs,    96 

and  247).  The  lower  end  of  the  jury  mast  is  incor- 
porated in  the  plaster  when  the  jacket  is  applied.    Calot, 


Fig.  247. — Jury  Mast. 


468 


TECHNIC 


for  the  same  purpose,  prolongs  the  jacket  upward,  bring- 
ing the  plaster  in  front  of  and  over  the  shoulders,  or 
includes  the  neck,  chin,  and  occiput,  or  even  the  whole 

head  (Figs.  97,  98,  99, 
and  248).  He  also  cuts 
a  large  window  in  front, 
since  this  is  not  needed 
for  a  counter  pressure, 
and  a  narrow  one  be- 
hind, over  the  kyphos, 
through  which  cotton  is 
packed  to  make  firmer 
pressure  in  order  to  re- 
duce the  deformity;  the 
window  is  then  replaced 
and  bandaged  down  with 
a  few  turns  of  plaster 
bandage.  The  plaster 
head  support  is  mechan- 
ically better  than  the 
Sayre  jury  mast,  but  is 
untidy  and  none  too 
comfortable.  When  there 
is  psoas  contraction  a 
short  spica  may  be  com- 
bined with  the  jacket, 
and  if  the  disease  is  at 
the  lumbo-sacral  junc- 
tion, a  double  spica  reaching  to  the  axillae  should  be 
applied,  or  the  child  placed  upon  a  frame. 

When  the  jacket  is  applied  for  scoliosis  the  leverage 


Fig.  248. — Plaster  Jacket  Including 
Head  and  Neck.     (Starr  and  Gallie.) 


SPLINTING— SPECIAL  4G9 

is  usually  from  the  side  or  diagonally.  It  should  be  ap- 
plied in  suspension  or  on  a  corrective  frame,  and  it  is 
well  to  pad  out  the  hollow  side  with  a  cotton  pad,  which 
is  to  be  removed.  If  the  shoulders  and  neck  are  included 
the  leverage  will  be  increased. 

Removable  jackets  are  called  corsets.  Corsets  should 
be  used  for  cases  of  Pott's  disease  only  after  patho- 
logical convalescence;  in  other  words,  when  the  patient 
is  practically  well  and  needs  only  moderate  support.  The 
plaster  is  applied  to  the  patient  as  for  a  plaster  jacket; 
when  the  plaster  has  set  it  is  cut  down  in  front  and 
sprung  off.  It  is  then  dried  at  300°  for  a  day;  the  edges 
are  trimmed,  bound  with  buckskin  or  rubber  adhesive, 
and  a  row  of  hooks  for  lacing  is  sewed  on  either  side  of 
the  cut  (Fig.  76).  The  corset  should  be  laced  when  the 
patient  is  lying  on  the  back,  as  it  can  be  laced  tighter  in 
this  posture.  Corsets  for  scoliosis  should  be  made  over 
a  cotton  pad  on  the  flattened  side,  which  is  removed  when 
the  corset  is  finished,  and  the  leverage  may  be  increased 
by  adding  layers  of  felt  inside  the  corset  over  the  prom- 
inence. Jackets  and  corsets,  if  made  over  a  cast  of  the 
torso,  may  be  made  of  paper,  felt,  celluloid,  and  leather 
(see  p.  419).  The  complicated  scoliosis  splints  of  the 
shops,  some  of  which  purport  to  reduce  torsion,  are  usu- 
ally valueless.  It  seems  practically  impossible  to  grasp 
the  pelvis  firmly  enough,  nor  will  the  patient  bear  suffi- 
cient continuous  pressure  to  produce  detorsion;  in  any 
event,  the  spinal  column  can  be  only  indirectly  attacked. 

The  Van  Winkle  corset  brace  is  a  spinal  splint  in  the 
form  of  a  woman's  corset;  it  has  given  great  satisfaction 
in  light  and  medium  cases  of  scoliosis  and  round-back 


470  TECHNIC 

(Fig.  73).  A  long,  straight  corset  of  strong  coutil  is  first 
made  to  measure;  it  is  imjDortant  to  cut  the  material 
square  with  the  fabric  to  avoid  stretching,  not  bias  as  is 
usually  done  in  corset  making.  At  the  first  fitting  strong 
steels  are  shaped  to  the  sides  of  the  back,  but  are  made 
the  same,  thus  exerting  pressure  on  the  prominent  side 
and  protecting  the  hollow  side.  A  pair  of  thinner  steels 
is  fitted  either  side  of  the  lacing,  and  another  between  the 
first  two.  At  the  second  fitting  the  steels  are  incorpor- 
ated in  the  corset,  and  broad  shoulder  straps  are  fitted 
which  start  at  buttons  under  the  arms,  pass  up  in  front 
of  and  over  the  shoulders,  cross  behind  the  scapulae, 
where  they  are  sewed,  and  attached  to  buckles  in  front 
of  the  iliac  spine.  These  straps  pull  the  shoulders  back- 
ward and  press  the  posterior  borders  of  the  scapulas 
forward.  To  the  front  of  the  corset  are  attached  strong 
stocking  supporters,  which,  when  tightened,  incline  the 
trunk  slightly  forward. 

Steel  Spinal  Splints. — The  simplest  and  most  directly 
acting  spinal  splint  is  probably  C.  F.  Taylor's,  which 
has  been  much  modified  in  various  hands,  but  scarcely 
improved  (Figs.  100  and  249).  This  apparatus  is  a 
spinal  lever,  consisting  of  two  uprights,  one  and  a 
quarter  inches  apart,  riveted  to  a  pelvic  band  of  17- 
gauge  steel  reinforced  by  a  shorter  band  inside.  The 
lower  edge  of  the  pelvic  band  just  clears  the  trochan- 
ters and  ends  at  a  point  just  above  their  middle.  The 
uprights,  made  of  mild  steel  -^  inch  wide  and  8  to 
10  gauge,  are  shaped  to  a  lead  tracing  of  the  back 
taken  over  the  laminae,  not  over  the  spinous  proc- 
esses; these  carry   steel  pad  plates  three  quarters  to 


SPLINTING— SPECIAL  471 

seven  eighths  inch  wide  and  six  or  eii^-ht  inches  long 
either  side  of  the  kyphos.  Steel  hooks  curving  over  the 
shoulders  near  the  neck  are  attached  to  the  top  of  the 
back  bars.  The  back  bars  are  united  by  a  cross  bar  at 
the  axillary  level,  and  a  second  cross  bar  two  inches 
lower.    The  pad  plates  carry  thick  pads  of  felt  or  ground 


Fig.  249. — C.  F.  Taylor  Spinal  Splints;  the  One  at  the  Left  has  the 
Vertical  U  Hip-Band;  the  One  at  the  Right  the  Horizontal  Hip- 
Band,  WHICH  IS  Easier  to  Fit. 

cork,  the  shoulder  hooks  carry  padded  webbing  straps, 
and  the  cross  pieces  and  pelvic  band  buckles  at  the  ends. 
The  bars  and  pelvic  band  are  lined  with  leather,  and  the 
splint  is  completed  by  an  apron  of  strong  drilling,  ex- 
tending from  the  top  of  the  sternum  to  the  pubes  in 
front,  and  is  provided  with  webbing  straps  above  and 
below,  and  two  or  three  pairs  in  between.     The  padded 


472  TECHNIC 

straps  of  tlie  shoulder  hooks  buckle  to  the  second  cross 
bar,  the  upper  straps  of  the  apron  buckling  to  the  first. 
The  leverage  is  exerted  by  the  pull  on  the  upper  and 
lower  apron  straps  and  the  shoulder  straps.  A  chest 
piece  similar  to  the  front  part  of  the  clavicle  splint 
(Figs.  109  and  110)  may  be  used  to 
increase  the  leverage  in  front.-  If 
the  disease,  however,  is  above  the 
tenth  dorsal,  it  is  necessary  to  add 
a  circular  chin  piece,  occipital  piece 
with  forehead  strap,  or  other  device, 
to  increase  the  leverage  (Fig.  250). 
Fig.  250.— C.  F.  Taylor  The  Splint  should  be  worn  day  and 
Circular  Chin  Sup-     mght,  and  the  child  sliould  never  sit 

PORT. 

up  when  being  bathed.  The  lever- 
age and  pressure  may  be  modified  as  the  case  progresses 
by  bending  the  back  bars. 

Neck  Splints. — If  spinal  tuberculosis  is  located  above 
the  tenth  dorsal  vertebra,  the  leverage  on  the  front  of  the 
chest  is  insufficient  to  give  the  proper  support,  and  the 
splint  should  therefore  be  jDrolonged  upward  to  grasp 
the  head,  and  pull  and  tilt  it  backward.  This  may  be 
done  by  adding  neck  and  head  parts  to  the  jacket  (Calot), 
by  adding  a  steel  jury  mast  to  the  jacket  (Sayre),  by 
adding  a  circular  chin  and  head  rest  (C.  F.  Taylor), 
and  by  other  devices. 

The  jury  mast  may  be  made  of  y^-inch  steel  of  8 
gauge;  it  curves  over  the  top  of  the  head  to  the  front, 
where  it  carries  a  steel  cross  piece,  with  pins  or  hooks 
for  attachiQg  the  head  better.  The  jury  mast  should  be 
made  rigid,  and  is  therefore  not  properly  a  head  spring. 


SPLTNTTNO— SPECIAL 


473 


The  levera,i>-e  is  obiaiiiod  l)y  ti,i^litoiiiii<2;-  the  liead  halter; 
there  is  little  or  no  vertical  traction  in  ijractice. 

'I'lic  Taylor  chin  rest  is  a  rigid  steel  ring,  cut  at  one 
side,  where  it  may  be  clamped  tog-ether,  and  jointed  on 


Fig.  251. — Taylor  Back  Splint  Applied.      This  patient  had  recession  of 
the  chin,  and  the  chin  siqjport  was  changed  for  a  forehead  strap. 


the  opposite  side.    It  carries  a  hard  rubber  rest  for  the 
chin  in  front  and  a  socket  behind,  which  is  placed  over  a 

32 


474 


TECHNIC 


pivot  at  the  top  of  the  spinal  splint.    The  tilt  may  be  in- 
creased or  diminished  bj^  bending  the  pivot  bar.    Liberal 

motion  is  usually  al 


lowed  unless  the  dis- 
ease is  very  high  up, 
when  the  pivot  joint 
may  be  clamped  by 
a  screw.  Both  the 
head  halter  and  chin 
rest  sometimes  cause 
recession  of  the  chin 
if  worn  for  a  long 
time.  This  may  be 
obviated  by  omitting 
the  chin  cup  in  either 
case  and  using  only 
a  strap  under  the 
chin.  This  may  be 
used  with  the  head 
rest  by  cutting  away 
the  front  and  adding 
two  vertical  bars  at 
the  sides  of  the  occi- 
put, which  turn  for- 
ward above  the  ears 
to  the  sides  of  the 
forehead  where  the  chin  strap  is  attached,  or  by  erecting 
from  the  half  circle  a  bar  in  front  of  the  ear  as  well  as 
behind,  and  connecting  them  by  a  strap  around  the  head 
(Fig.  251).  This  arrangement  is  somewhat  less  effective, 
but  saves  the  chin  from  front  pressure.    Head  supports 


Fig.  252. — Plaster-of-P^^is  Neck  Splint. 


SPLINTING— SPECIAL 


475 


taking  the  shoulders  for  a  base  are  not  very  efficient  in 
active  cervical  tuberculosis,  but  are  useful  in  some 
conditions  where  less  perfect  fixation  is  required.  The 
Thomas  collar  is  a  leather  tube  much  deeper  in  front, 
stuffed  with  hair  or  pow- 
dered cork.  It  opens  be- 
hind, and  fastens  with  a 
buckle.  If  constructed 
over  a  rigid  padded 
frame,  it  keeps  its  shape 
better.  A  collar  may 
be  improvised  by  apply- 
ing layers  of  cotton 
about  the  neck,  thicker 
in  front  or  on  the  side 
which  needs  most  sup- 
port, and  held  in  place 
by  a  bandage  over 
which  adhesive  plaster 
is  wound. 

A  plaster  -  of  -  Paris 
splint  may  be  applied  to 
the  neck  and  shoulders 
(Fig.  252),  or  a  wire 
skeleton  splint  may  be 
applied  to  the  head  and 
shoulder  of  one  side  for 
lateral  action;  it  should 
be  wound  with  a  bandage 

and  be  well  padded ;  it  may  pass  behind  the  ear  or  both 
sides  of  it,  and  is  kept  in  place  by  a  strap  from  the 


Fig.    253. — Wire    Neck    Splint    for 
L.\TERAL  Support. 


476  TECHNIC 

middle,  which  passes  under  the  arm  of  the  opposite  side 
and  buckles  to  the  middle  in  front  (Fig.  253;  see  also 
Fig.  38).  Such  retention  splints  are  useful  in  some  of 
the  forms  of  torticollis  where  the  deformity  is  not  great 
or  where  the  splint  does  not  have  to  be  worn  long. 
Where  there  is  structural  shortening  of  the  sterno- 
mastoid  or  other  muscles  a  stretching  or  cutting  opera- 
tion will  be  required. 


LITERATURE 


LITERATURE 


A  partial  list  of  orthopedic  literature  fills  a  large  volume,  and 
has  been  pul^lished  by  Hoffa  and  Blenke.  The  titles  given  here 
are  such  recent  works  as  have  been  of  most  value  in  the  prepara- 
tion of  this  volume. 

AMERICAN   AND    ENGLISH 

American  Journal  of  Orthopedic  Surgery,  1903  to  date. 

American  Orthopedic  Association  Transactions,  1889-1902. 

Bradford  and   Lovett,    "Orthopedic   Surgery/'   third  edition. 
AVood,  New  York,  1905. 

DwiGHT,    "Variations   of   the   Bones   of   the   Hands   and   Feet." 
Lippincott,  Philadelphia,  1907. 

Lovett,  "Lateral  Curvature  of  the  Spine."     Blakiston,  Philadel- 
phia, 1907. 

Roth,  "Treatment  of  Lateral  Curvature  of  the  Spine,"  second 
edition.     Lewis,  London,  1899. 

Taylor  (R.  Tunstall),  ''The  Spine,"  Williams  and  Wilkins  Co., 
Baltimore,  1907. 

Thorndike,  "A  Manual  of  Orthopedic  Surgery,"  Blakiston,  Phila- 
delphia, 1907. 

Tubby,  "Deformities."     Macmillan,  London,  1896. 

Tubby  and  Jones,  "Modern  Methods  in  the  Surgery  of  Paralysis." 
Macmillan,  London,  1903. 

Whitman,  "Orthopedic  Surgery,"  third  edition.     Lee.  Philadel- 
phia, 1907. 

Waltham   and   Hughes,    "Deformities   of   the   Human   Foot." 
Wood,  New  York,  1895. 

479 


480  LITERATURE 

FREXCH 

Beeger  et  Banzet,  "Chirurgie  orthopeclique."     Steinheil,  Paris, 
1904. 

Calot,  "  Luxation  congenitale  de  le  hanche/'    Masson^  Paris,  1905. 

Calot,  "Tumeurs  blanches."     Masson,  Paris,  1906. 

DucROQUET,    "  Trait e   de  therapeutique   orthopedique."     I.    Les 
tuberculoses  osseuses.     Rousset,  Paris,  1907. 

KiRMissoN,  "Traite  des  maladies  chirurgicales  d'origine  congeni- 
tale."    Masson,  Paris,  1898. 

Redard,  "Traite  pratique  des  deviations  de  la  colonne  vertebrale." 

Masson,  Paris,  1900. 
Redard,  "Technique  orthopedique."     Rudeval,  Paris,  1907. 

Revue  d'orthopedie,  1890  to   date.     Edited   by  Kirmisson.     Mas- 
son,  Paris. 

GERMAN 

Archiv  filr  Orthopddie,  Mechanotherapie  und  Unfallchirurgie.     Ed- 
ited by  Riedinger.     Bergmann,  Wiesbaden,  1903  to  date. 

Handbuch  der  Orthopadischen  Chirurgie.    Edited  by  Joachimsthal. 
Fischer,  Jena,  1904-1907. 

Haudek,     "Grundriss    der    Orthopadischen    Chirurgie."     Enke, 
Stuttgart,  1906. 

HoFFA,  "  Orthopadische  Chirurgie,"  fifth   edition.     Enke,  Stutt- 
gart, 1906. 

HoFFA   AND    Blenke,    "Die    Orthopadische    Literatur."     Enke, 

Stuttgart,  1905. 
Klapp,  "  Funktionelle  Behandlung  der  Skoliose."     Fischer,  Jena, 

1907. 
Klaussner,     "tJber    Missbildungen."     Bergmann,     Wiesbaden, 

1902. 

KoNiG,  "Tuberkulose  der  Menschhchen  Gelenke."     Hirschwald, 
Berhn,  1906. 

Krause,    "Tuberkulose   der   Ivnochen  und  Gelenke."     Deutsche 
Chirurgie,  No.  28A.     Enke,  Stuttgart,  1899. 


LITERATURE  481 

LoRKNZ,  "Heilunu;  der  Angeborenen  Hiiftgelenksverrenkungen." 
Deuticke,  Leipzig,  1900. 

LiJNING    UND   SCMULTIIKSS,    "  AtlilS    Ulld    ('.  I-UIK  liiss    (Icr   Orlliopfi- 

dischen  Chirurgie."     Lehmann,  Munich,  1901. 
Von  Mikulicz  und  Tomasczewski,  "Orthopiidische  Clymnastik." 

Fischer,  Jena,  1902. 
ScHANZ,    "Handbuch    der    Orthopadischcn    Tcclinik."     Fischer, 

Jena,  1908. 
ScHUCHARDT,  "  Krankhcltcn  der  Knochcn  und  Gelenke."  Deutsche 

Chirurgie,  Lieferung  28.     Enke,  Stuttgart,  1899. 
Zeitschrift  filr  Orthopddische  Chirurgie.     Edited  by  Hoffa.     Enlce, 

Stuttgart,  1892  to  date. 
Zentralblatt  fiir  Chirurgische  und  M echanische  Orthopddie.     Edited 

by  Vulpius.     Karger,  Berlin,  1907  to  date. 

Preliminary  Studies  by  the  Author 
(Upon  Which  Parts  of  the  Present  Volume  are  Based) 

general 

"Principles  and  Methods  of  Examination  in  Orthopedic  Practice." 

Maryland  Medical  Journal,  July  20,  1889. 
"The    Orthopedic    Examination    of    Children."     Post-Graduate, 

January,  1907. 

"Infantile  Scorbutus."     jhnerican  Medico-Surgical  Bulletin,  Feb- 
ruary 1,  1894. 

"Infantile  Scorbutus  and  Its  Relation  to  Orthopedic  Practice." 
Archives  of  Pediatrics,  September,  1894. 

"Surgery  of  Rickets."     Journal  of  American  Medical  Association, 
October  11,  1902. 

"Osteitis    Deformans    (Paget)."     Medical    Record,    January    21, 
1893. 

"Chronic  Joint  Disease  in  Children."     Medical  News,  August  19, 
1902. 

"Mechanical   Treatment   of   Non-tuberculous   Joint   Infections." 
New  York  State  Journal  of  Medicine,  April,  1907. 


482  LITERATURE 

"The    Management    of    Infantile    Cerebral    Palsies/'     Medical 

Progress,  October,  1896. 
"The  Treatment  of  Tuberculous  Joint  Disease."     Post-Graduate^ 

October,  1907. 
"The    Fresh    Air    Treatment    of    Surgical    Tuberculosis."     Post- 

Gradiiate,  Memorial  Volume,  1908. 
"Remarks    on    the    Management    of    Suppuration    Complicating 

Tuberculous  Disease  of  the  Bones  and  Joints."     Annals  of 

Surgery,  April,  1893. 
"Reports  on  Orthopedic  Surgery."     Neiv  York  Medical  Journal, 

February  25,  July  8,  December  30,  1893 ;  September  15,  1894. 
"The  Present  Status  of  Practical  Orthopedics."     Medical  News, 

October  2,  1897. 
"Recent    Advances    in    Orthopedic    Surgery."     Medical    News, 

October  10,  1903. 

THORAX    AND    SPINE 

"Imperfect  Development  of  the  Right  Pectoralis  Major  and 
Right  Scapula."     Pediatrics,  February  15,  1900. 

"Deformities  of  the  Chest."  Reference  Handbook  of  the  Medical 
Sciences,  1901. 

"Treatment  of  Lateral  Curvature  of  the  Spine."  Neio  York 
Medical  Journal,  November  15,  1890. 

"Congenital  Lateral  Curvature  of  the  Spine."  Pediatrics,  Janu- 
ary 15,  1900. 

"Neurotic  Spine."     Pediatrics,  November  15,  1899. 

"Location,  Age,  and  Sex  in  Pott's  Disease  of  the  Spine."  Medical 
Record,  August  13,  1881. 

"The  Paralysis  of  Pott's  Disease  and  Its  Behavior  Under  Pro- 
tective Treatment"  (with  R.  W.  Lovett).  Medical  Record, 
June  19,  1886. 

"The  Cure  of  Pott's  Disease  with  Recession  of  the  Deformity." 
Medical  Record,  January  8,  1887. 

"A  Case  of  Pott's  Disease  with  Unusual  Deformity.  Descrip- 
tion of  Improved  Spinal  Apparatus."  Medical  Record,  No- 
vember 19,  1887. 


LITERATURE  483 

"The  Value  of  Mcchiiuical  Tieatiucnt  in  Okl  and  Neglected 
Cases  of  Pott's  Disease."     Medical  News,  December  5,  1891. 

"Improved  Apparatus  for  Pott's  Disease  of  the  Spine."  Canada 
Medical  Record,  November,  1893. 

"Growth  in  Spondylitics."     New  York  Medical  Journal,  October 

8,  1898. 
"A  Bivalve  Plastic  Splint  for  Pott's  Disease."     Pediatrics,  1898. 
"Final  Results  After  the  Mechanical  Treatment  of  Pott's  Disease." 

Transactions  American  Orthopedic  Association,  1902. 
"Ultimate  Results  of  Mechanical  Treatment  of  Pott's  Disease  in 

Dispensary     Practice."     American     Journal     of     Orthopedic 

Surgery,  October,  1904. 
"Common  Deformities  of  the  Spine."     Post-Graduate,  July,1904. 

UPPER    EXTREMITY 

"A  New  Clavicle  Splint."     Pediatrics,  December  1,  1899. 
"Isolated  Fracture  of  the  Greater  Tuberosity  of  the  Humerus." 

Annals  of  Surgery,  January,  1908- 
"Congenital   Absence    of   the   Radius."     Transactions   American 

Orthopedic  Association,  1897. 

LOWER    EXTREMITY 

"Primary  Crural  Asymmetry."     Medical  Record,  August  13,  1881. 
"Two  Cases  of  a  PecuUar  Type  of  Primary  Crural  Asymmetry." 

University  Medical  Magazine,  October,  1891. 
"Affections  of  the  Sacro-iliac  Joints."     Post-Graduate,  September, 

1905. 

HIP 

"Laxity  of  the  Ligaments  with  Congenital  Hip  Luxation."     New 

England  Medical  Monthly,  February,  1898. 
"  Peripheral  Palsies  Following  Manual  Replacement  of  the  Con- 

genitally    Dislocated    Hip."     New    York    Medical    Journal, 

August  8,  1903. 
"Progress   in   the   Treatment    of   Congenital   Hip   Dislocation." 

Post-Graduate,  October,  1903. 


484  LIT^ERATURE 

"Case  of  Congenital  Supracotyloid  Dislocation  of  the  Hips  with 
Cross-legged  Progression/'  American  Medicine,  September 
24,  1904. 

"The  Mechanical  Treatment  of  Senile  Coxitis."  New  York  Medi- 
cal Journal,  December  15,  1888. 

"A  New  Method  for  Overcoming  Adduction  at  the  Hip-joint." 
New  York  Medical  Journal,  November,  19,  1887. 

"The  Rational  Treatment  of  Hip  Disease."  Times  and  Register, 
April  26,  1890. 

"Adjusted  Locomotion  in  the  Recovering  Stage  of  Hip-joint 
Disease."     New  York  Medical  Jouriuil,  July  11,  1891. 

"The  Prevention  and  Treatment  of  Crural  Adduction."  Medi- 
cal News,  March  23,  1889. 

"Improved  Long  Traction  Hip-splint,  with  Proper  Method  of 
Applying  Adhesive  Plaster."  Southern  Medical  Record, 
November,  1893. 

"Ankylosis  of  the  Hip  Joint."     Pediatrics,  August  15,  1899. 

"Retardation  of  Growth  as  a  Cause  of  Shortening  After  Coxitis." 
Philadelphia  Medical  Journal,  January  26,  1901. 

KNEE   AND    LEG 

"A  Ready  Method  for  Counter-extension  at  the  Knee."  Boston 
Medical  and  Surgical  Journal,  October  16,  1890. 

"The  Mechanical  Treatment  of  Osteitis  of  the  Knee."  New 
York  Medical  Journal,  November  18,  1893. 

"The  Thomas  Knee-spHnt."     Pediatrics,  March  1,  1900. 

"The  Effect  of  Osteitis  of  the  Knee  on  the  Growth  of  the  Limb." 
New  York  Medical  Journal,  April  19,  1902. 

"  Deformity  Following  Excision  of  the  Knee."  Pediatrics,  Decem- 
ber 15,  1899. 

"Enlargement  of  the  Tibial  Tubercle."  Pediatrics,  August  1, 
1899. 

"Affections  and  Injuries  of  the  Patella."  Reference  Handbook  of 
the  Medical  Sciences,  1903. 


LITERATURE  485 

"  Congenital  Luxation  of  the  Knee."     Pediatrics,  February  1, 1896. 
"Specific  Necrosis  of  the  Shaft  of  the  Tibia."     Pediatrics,  Septem- 
ber 15,  1899. 
"Absence  of  Fibula."     Pediatrics,  October,  1899. 


FOOT 

"The  Treatment  of  Pes  Equino- Varus  by  Continuous  Leverage." 
Medical  Record,  March  8,  1890. 

"The  Treatment  of  Club-foot  by  Continuous  Leverage."  New 
York  Medical  Journal,  November  19,  1892. 

"Congenital  Club-foot;  Equino- Varus."  Pediatrics,  September  1, 
1899. 

"Double  Paralytic  Varus  from  Peripheral  Neuritis."  Pediatrics, 
January  1,  1900. 

"Practical  Importance  of  Correct  Foot  Postures."  American 
Journal  of  Orthopedic  Surgery,  July,  1905. 

"Ingrown  Toe-nail  Mechanically  Treated."  American  Medico- 
Surgical  Bidletin,  June  20,  1896. 

THERAPEUTIC    EXERCISES   AND    PHYSICAL   TRAINING 

"Hygiene  of  Reflex  Action."  Journal  of  Nervous  and  Mental 
Disease,  March,  1888. 

"American  Childhood  from  a  Medical  Standpoint."  Popular 
Science  Monthly,  October,  1892. 

"Exercise  as  a  Remedy."     Popular  Science  Monthly,  March,  1896. 

"Therapeutic  Value  of  Systematic  Passive  Respiratory  Move- 
ments."    Medical  Record,  May  4,  1889. 

"Physical  Training  in  the  Public  Schools."  Dietetic  and  Hygienic 
Gazette,  September,  1897. 

"Exercise  and  Vigor."  American  Physical  Education  Review, 
December,  1898. 

"Exercise."     Practical  Therapeutics,  1896. 

"Massage."     Practical  Therapeutics,  1896. 

"Infantile  Athletics."     Babyhood,  May,  1897. 


486  LITERATURE 

"The  Work  of  Charles  Fayette  Taylor,  M.D.,  in  the  Field  of 
Therapeutic  Exercises."  American  Physical  Education  Re- 
view, September,  1899. 

"The  Foot  in  Gymnastics."  American  Physical  Education  Re- 
view, December,  1902. 

"The  Dancing  Foot."  American  Physical  Education  Review, 
June,  1905. 


INDEX 


INDEX 


Abdominal  glands,  tuberculosis    of, 

197. 
Absence,     complete    or    partial,     of 
clavicle,  205. 
of  femur,  303. 
of  fibula,  335. 
of  fingers,  233. 
of  humerus,  222. 
of  metacarpals,  233. 
of  metatarsals,  335. 
of  patella,  308. 
of  pectoral  muscle,  110. 
of  radius,  226. 
of  ribs,  110. 
of  sternum,  110. 
of  tibia,  336. 
of  toes,  392. 
of  ulna,  226. 
of  vertebrae,  117. 
Abscess,  85. 

Brodie's  (quiet  bone),  305. 
cold,  39. 
of  hip,  274. 
psoas,  176,  183. 
Accelerated    growth    of    limb    from 

gonitis,  324. 
Acetabulum,  tuberculosis  of,  272. 

wandering,  272. 
Achillobursitis,  anterior,  386. 
Achillotenontitis,  387. 
Achillotomy,  368. 
Achondroplasia.        See   Chondrodys- 

trophia,  10. 
Acromegaly,  50. 
Acute  anterior  poliomyelitis,  66. 


Acute  osteomyelitis,  28. 

diagnosis  of,  30. 

prognosis  of,  31. 

symptoms  of,  28. 

treatment  of,  31. 
Adhesive  plaster,  403. 

for  club-foot,  362. 

for  hip  traction,  286. 

for  knee  traction,  326. 
Adhesive  strapping  for  flat-foot,  376. 

for  sprain  of  ankle,  346. 
Adjustable  fixation  splints,  423. 
Affections,  nervous,  63. 
Albee's  operation  toankylose  hip,  299. 
Albee's  posture  in  juxta-epiphyseal 
fracture  of  upper  end  of  hu- 
merus, 218. 
Angina  cruris,  344. 
Ankle,  splints  for,  370,  432. 

sprain  of,  345. 

tuberculosis  of,  347. 

weak,  345. 
Ankylosis,  88. 

of  hip,  274,  288. 

of  knee,  329. 

of  spine,  200. 
Anterior  bow-legs,  340. 
Anterior  curvature  of  the  tibia,  340. 
Anterior  poliomyelitis,  66. 
Arch  supports,  378,  418. 
Arm  splints,  457. 
Arthritis,  gonorrheal,  24. 

infectious,  33. 

purulent,  27. 

villous,  44,  332. 


33 


'■  Consult  also  the  Contents. 


489 


490 


INDEX 


Arthritis  deformans,  45. 

of  hip,  297. 

of  spine,  200. 
Arthrodesis,  95. 

of  ankle,  384. 
Atrophy,  89. 
Axillary  web,  211. 

Back.     See  Spine. 

Bandaging,  402. 

Beck's     (E.     G.),     bismuth-vaseline 

treatment  of  sinuses,  87. 
Benign  (bone)  cysts,  56. 

of  femur,  306. 

of  tibia,  57. 
Bibliography,  479. 
Birth  fractures,  73. 
Birth  palsy,  212. 
Birth  torticollis,  101. 
Bismuth-vaseline  paste  for  pockets 

and  sinuses,  87. 
Bivalve  plaster  splints,  413. 
Blanchard  on  osteoclasis  below  the 

knee,  for  knock-knee,  318. 
Bone,  dancers',  54. 

fencers',  54. 

riders',  54. 
Bone  tumors,  53. 

carcinoma,  61. 

hypernephroma,  60. 

myeloma,  61. 

osteochondroma,  53. 

osteoma,  54. 

sarcoma,  59. 
Bone  wax,  32. 
Bow-legs,  337. 

anterior,  '340.  » 

reversed,  340. 
Brace.     See  Splint. 
Bradford  frame,  461. 
Bradford  on  hump-foot,  388. 
Bradford-Goldthwait  knee  corrector, 

329. 
Brodie's  abscess,  305. 
Burrell's  operation  for  recurrent  dis- 
location of  the  shoulder,  215. 


Bursitis,  above  elbow,  224. 
achillo-,  386. 
prepatellar,  309. 
pretibial,  310. 

pretubercular,  310.  ■* 

subacromial,  221. 
subdeltoid,  219. 

Calcaneus,  381. 

Whitman's  sphnt  for,  433. 
Caliper  knee  splint,  441. 
Calluses,  391. 

Calot  jacket,  191,  192,  468. 
Calot's  after  treatment  of  congenital 

hip  dislocation,  261. 
Calot's  illustrations  of  knee  splinting, 

408,  438,  442. 
Calot's    manipulations   for    reducing 
congenital  dislocation  of  hip, 
259. 
Casts,  415. 

of  feet,  375,  416. 
Cavus,  386. 
Cerebral  palsies,  64. 
Cervical  rib,  108. 

Cervical  spine,  dislocation  of,  105. 
Cervical  spondyhtis  deformans,  107. 
Cervical  spondyhtis  tuberculosa,  107. 
Charcot's  joint,  70. 
Charcot's  knee,  331. 
Chest,  deformities  of,  109. 
funnel,  110. 
normal,  109. 
primitive,  109. 
Chilblains,  391. 
Chondrodystrophia  fetalis,  10. 
Clavicle,  absence  of,  205. 
fracture  of,  205. 

safety-pin  dressing  for,  206. 
C.  F.  Taylor's  splint  for,  206. 
Claw-foot,  389. 
Claw-hand,  230. 
Cold  abscess.    See  Ichor  Pocket. 
Congenital  crippling  affections,  8. 
Congenital     defects.       See    Absence 
of. 


INDEX 


491 


Congenital  deformities  of  arm,  222. 
of  femur,  303. 
of  fingers,  233. 
of  foot,  3,'>5,  371,  382. 
of  forearm,  226. 
of  hand,  227. 
of  hip,  246,  263. 
of  knee,  306. 
of  leg,  335. 
of  neck,  101. 
of  sacrum,  118. 
of  scapula,  208. 
of  shoulder,  211. 
of  thorax,  109. 
of  toes,  392. 
of  vertebrae,  117. 
Congenital    dislocation    of    the    hip,. 
246. 
diagnosis  of,  253. 
etiology  of,  247. 
frequency  of,  246. 
methods  of  replacement  by  Calot, 
259. 
Davis,  259. 
Lorenz,  257. 
Paci,  254. 
Ridlon,  258. 
Schanz,  258. 
Schede,  254. 
pathological  anatomy  of,  247. 
prognosis  of,  254. 
symptoms  of,  249. 
treatment  of,  254. 
Congenital  dislocation  of  the   knee, 

308. 
Congenital  dislocation  of  the  shoul- 
der, 212. 
Congenital  dislocation   of   the   wrist, 

228. 
Cook's  modification  of  Thomas  heel, 

374. 
Corns,  391. 

Corrective  exercises.    See  Exercises. 
Cowp  de  fouet.     See  Plantaris  Tendon, 

rupture  of,  344. 
Coxa  valga,  267. 


Coxa  vara,  263. 

cervical,  263. 

epiphyseal,  263. 
Coxitis,  ankylosis  in,  276. 

diagnosis  of,  281. 

j)athological  anatomy  of,  269. 

prognosis  of,  293. 

symptoms  of,  275. 

treatment  of,  283. 
mechanical,  283. 
operative,  291. 
Coxitis  gonorrhoeica,  296. 
Coxitis  osteoarthritica,  297. 
Coxitis  senilis,  297. 
Coxitis  suppurativa,  295. 
Coxitis  tuberculosa,  269. 
Cramps,  professional,  237. 
Cretinism.    See  Myxedema. 
Crippling  affections,  congenital,  8. 

infectious,  20. 

malignant,  59. 

nervous,  63. 

nutritional,  12. 

of  unknown  origin,  44. 

traumatic,  61. 

tumors  and  cysts,  cause  of,  53. 
Cysts  of  bone,  56. 

of  femur,  306. 

of  tibia,  57. 

Dancers'  bone,  54. 

Dane's  observation  on  bow-legs,  338. 
Dangle  foot,  386. 
Dangle  shoulder,  213. 
Davis's  (Gwilym)   method  of  reduc- 
ing  congenital   dislocation   of 
the  hip,  259. 
Davis  (H.  G.),  4. 
Deformities,   causation  of,  6. 
acquired,  6. 
birth,  6. 
congenital,  6. 
of  arm  (upper  extremity),  211. 
of  chest,  109. 

of  leg  (lower  extremity),  245. 
of  neck  (thorax),  101. 


492 


INDEX 


Deformities  of  pelvis,  118,  239. 

of  shoulder  girdle,  205. 

of  spine,  117. 

of  sternum,  110. 
Deformity,    Sprengel's,    of    scapula, 

208. 
Diagnosis  in  orthopedic  practice,  71. 
Diseases   of  bones   and  joints,    con- 
genital, 8. 

infectious,  20. 

malignant,  59. 

nutritional,  12. 

of  unknown  origin,  44. 

tumors  and  cysts,  53. 
Diseases  of  nervous  system,  63. 

cerebral,  64. 

functional,  70. 

peripheral,  63. 

spinal,  65. 

trophic,  70. 
Dislocation,  recurrent,  of  patella,  311. 

of  shoulder,  214. 
Dislocation  of  cervical  spine,  105. 

bilateral,  105. 

unilateral,  105. 
Dislocation  of  hip,  congenital,  246. 

paralytic,  268. 

pathological,  273. 
Dislocation  of  knee,  congenital,  308. 
Dislocation  of  peroneal  tendons,  381. 
Droop  shoulders,  209. 
Drop  phalangette,  234. 
Drop-foot.     See  Equinus,  366. 
Drop-hand,  239. 
Ducroquet's  apparatus,  451. 
Dupuytren's   contraction  of  fingers, 

235. 
Dysbasia  angiosclerotica.    See  Angina 
Cruris,  344. 

Echol's  traction  appliance,  449. 
Elbow,  bursitis  of,  224. 

congenital  anomalies  of,  222. 

cubitus  valgus,  deformity  of,  222. 

cubitus  varus,  deformity  of,  222. 

fracture  of,  223. 


Elbow,  infections  of,  224. 

osteomata  about,  224. 
Enchondroma,  53. 
Epiphysitis,  27. 

of  hip,  295. 

purulent,  of  infancy,  27. 
Equino-varus,  355. 
Equinus,  366. 
Erb's  palsy,  212. 

Examination  in  orthopedic  practice, 
71. 

history  in,  75. 

laboratory  aids  in,  77. 

records  of,  75. 

skiagraphy  in,  78. 
Excision  of  hip,  291. 

of  knee,  327. 
Exercises,  96. 

for  round  back,  125. 

for  scoliosis,  165. 

for  weak  feet,  374. 

Femur,    absence   and   anomalies    of, 
303. 

bowed,  306. 

cysts  of,  306. 

flexed,  306. 

fracture  of  neck  of,  302. 

osteomyelitis  of,  305. 

phocomelia  of,  303. 

sarcoma  of,  305. 
Fencers'  bone,  54. 
Fibula.    See  Tibia  and  Fibula,  335. 
Finger,    absence    of,   233.     See    also 
Hand  and  Phalangitis. 

deviation  of,  234. 

drop  phalangette  in,  234. 

Dupuytren's  contraction  of,  235. 

hysterical  contraction  of,  238. 

Krukenberg's  deformity  of,  236. 

stiffness  of,  237. 

supernumerary,  233. 

trigger,  237. 

tuberculosis  of,  37. 

webbed,  233. 
Flail  ankle,  386. 


INDEX 


493 


Flail  foot,  386. 
Flail  knee,  320. 
Flail  shoulder,  213. 
Flat-foot,  375. 
Floating  bodies,  333. 
Floating  elbow,  224. 
Floating  knee,  333. 
Foot,  natural  shape  of,  350. 

I>hysiological  anatomy  of,  350. 

I^osture  of,  in  walking,  115,  355. 
Foot  deformities,  calcaneo- valgus,  381 . 

calcaneus,  381. 

cavus,  386. 

equino-varus,  355. 

equinus,  366. 

valgus,  371. 

varus,  355. 
Foot  plates,  376,  418. 
Foot  splints,  359,  431. 
Forcible  correction,  94.    See  also  Hip, 

Knee,  and  Foot. 
Forearm,  226. 

congenital  defects  and  anomalies  of, 
226. 

deformity  of,  after  fracture,  227. 
Forward  shoulders,  209. 
Fracture,  spontaneous,  61. 

Pott's,  371. 

ununited,  62. 
Fracture  of  clavicle,  206. 

of  elbow,  222. 

of  femoral  neck,  302. 

of  humerus,  217. 

greater  tuberosity,  217. 
juxta-epiphyseal  of  upper  end, 
217. 

of  radius,  227. 

of  spine,  200. 
Fragilitas  ossium.      See  Osteodystro- 
phia fetalis,  12. 
Free  joint,  430. 

Freiberg's  method  of  taking  imprints 
of  the   sole,  373. 

Gallie's  hip  rest,  447. 
hip  splint,  456. 


Ganglion  of  wrist,  232. 

Gant's  osteotomy  for  deformity  of  the 

hip,  288. 
General  part,  1. 
Genu  recurvatum,  308. 
acquired,  309. 
paralytic,  309. 
rachitic,  341. 
congenital,  308. 
Genu    valgum.         See  Knock-Knee, 

313. 
Genu  varum.     See  Bow-Legs,  337. 
Gibney's  adhesive  strapping  for  sprain 

of  ankle,  346. 
Gibney's  operation  for  spastic  inver- 
sion of  thigh,  269. 
Gigantism,  9. 

Goldthwait's  (Joel  E.)  operation  for 
bowed  scapula,  208. 
for  slipping  patella,  312. 
Gonitis  tuberculosa,  322. 
diagnosis  of,  325. 
pathological  anatomy  of,  322. 
prognosis  of,  325. 
symptoms  of,  323. 
treatment  of,  325. 
hygienic,  325. 
mechanical,  325. 
operative,  327. 
treatment  of  deformities  in,  329. 
Gonorrheal  arthritis  (and  ostitis),  24. 
of  feet,  27,  380. 
of  heel,  27,  386. 
of  spine,  27,  201. 
of  wrist,  232. 
Gonorrheal  coxitis,  296. 
Gonorrheal  gonitis,  330. 
Gout,  19. 

Grattan's  osteoclast,  318,  339. 
Groove,  Harrison's,  14,  112. 
Growth,  accelerated,  in  gonitis,  324. 
retarded  in  coxitis,  201. 

in  spondylitis,  195. 
unequal,  of  limbs,  303. 
Gymnastic  treatment,  95.      See  also 
Exercises. 


494 


INDEX 


Hallux  rigidus,  395. 
Hallux  valgus,  393. 
Hallux  varus,  395. 
Hammer-toe,  396. 
Hand,  227. 

club,  227. 

congenital  dislocation  of,  227. 

hemiplegic  deformities  of,  229. 

lobster-claw  deformity,  227. 

spastic  deformities  of,  229. 

subluxation  of,  228. 

Volkmann's     ischemic     palsy     of, 
230. 
Harrison's  groove,  14,  112. 
Heel  affections,  386. 

achillobursitis,  386. 

achillotenontitis,  387. 

talalgia  from  osteophytes,  387. 
Hemophilia,  18. 
Hip  deformities,  345. 

after  tuberculosis,  287. 

coxa  vara,  263. 

spastic  and  paralytic  contractions, 
268. 
Hip  joint,  congenital  dislocation  at, 
246. 

epiphysitis  of,  295. 

infections  of,  294. 

osteoarthritis  of,  297. 

tuberculosis  of,  276. 
Hip  rest,  Ducroquet's,  451. 

EchoFs,  449. 

Gallie's,  447. 

Hospital  for  Ruptured  and  Crip- 
pled, 447. 

Sanderson's,  448. 

Schultze's,  414. 
Hip  splints,  fixation,  446. 

Gallie's,  456. 

Hospital  for  Rujotured  and  Crip- 
pled, 286,  455. 

Phelps's,  285,  455. 

Plaster-of-Paris  spica,  452. 

Taylor's,  285,  454. 

Thomas's,  454. 
History  taking,  75. 


Hofifa's  operation  for  congenital  dis- 
location of  the  hip,  254. 
for  hyperpronation  of  the  forearm, 
225. 
Hoffmann,   studies   in  posture,   115, 

350. 
Hook  for  ingrown  toe-nail,  396. 
Hooks  for  bending  steel  bars,  414. 
Humerus,  congenital  deformities  of, 
222. 
fracture  of  the  greater  tuberosity 

of,  217. 
juxta-epiphyseal    fracture    of    the 

upper  end  of,  217. 
phocomelia,  222. 
Hump-foot,  388. 
Hydrops,  chronic,  of  knee,  321. 

intermittent,  of  knee,  321. 
Hypernephroma,  60. 
Hyperostosis  of  the  skull,  50. 
Hypertrophy,  congenital,  of  leg,  9. 

of  toes,  393. 
Hysteria,  70. 
Hysterical  finger  contraction,  238. 

Ichor,  37. 

Ichor  pockets,  39. 

In-ankle.     See  Weak  Ankle. 

Infantile  epiphysitis,  27. 

Infantile  paralysis,  66. 

Infantile  scurvy,  17. 

Infections  of  bones  and  joints,  20. 
See  also  the  individual  joints. 

Infectious  arthritis,  33. 

Ingrown  toe-nail,  396. 

In-knee.     See  Knock-Knee,  313. 

Intermittent  claudication.  See  An- 
gina Cruris,  344. 

Intermittent  hydrops  of  the  knee, 
321. 

Internal  derangement  of  knee,  334. 

Joint  affections,  diseases,  and  de- 
formities. See  Individual 
Joints. 

Joint  mice,  333. 


INDEX 


495 


Jointed  splints,  430,  445. 
Jones  (Robert),  adjustable  splints  of, 
423. 
incision    of,    for    exposing    osteo- 
phytes of  OS  calcis,  388. 
method  of,  for  correcting  7nain  en 

griffe,  230. 
operation   of,  for   calcaneo-valgus, 
384. 
for  palsy  of  elbow,  225. 
for  relapsing  flat-foot,  379. 
for  spastic   adduction   of   thigh, 
269. 
tenotome  of,  368. 
Judson,  club-foot  splint,  359,  435. 
Jury-mast,  190,  467. 

Knee  (see  also  Patella),  306. 

acquired  deformities  of,  paralytic, 
318. 

pathological,  329. 

spastic,  318. 
arthritis  deformans  of,  331. 
bursitis  about,  309. 

popliteal,  3]  1. 

prei^atellar,  309. 

pretibial,  310. 

pretubercular,  310. 
Charcot's,  331. 
clicking,  307. 
congenital  deformities  of,  306. 

dislocation,  308. 

flexion,  306. 

genu  recurvatum,  308. 

hyperextension,  308. 
hemarthros  of,  18. 
hydrops  of,  chronic,  321. 

intermittent,  321. 
infections  of,  330. 

gonorrheal,  330. 

purulent,  330. 

syphilitic,  330. 
internal  derangement  of,  334. 
lipoma  arborescens  of,  333. 
osteoarthritis  of,  331. 
synovitis  of,  320. 


Knee,  synovitis  of,  acute,  320. 

chronic  tuberculous,  322,  325. 
syphilis  of,  330. 

tuberculosis    of.     See   Gonitis  Tu- 
berculosa, 322. 
villous  arthritis  of,  332. 
Knee  splints,  437. 
caliper,  441. 
correction,  441. 
fixation,  437. 
movable,  442. 
Thomas,  439. 
Knight's  bow-leg  splints,  337,  339. 
Knock-knee,  313. 
treatment  of,  315. 
hygienic,  315. 
mechanical,  315. 
operative,  315. 
Kocher's  fish-hook  incision  for  arthro- 
desis of  ankle,  336. 
Krukenberg's  finger  deformity,  236. 
Kiimmel's  disease  of  the  spine,  199. 
Kypho-scoliosis,  151. 
Kyphosis,  119. 

Lateral  curvature   (scoliosis)  of  the 

spine,  135. 
Leg  (knee  to  ankle)  deformities,  335. 

angina  cruris,  344. 

rupture  of  plantaris,  344. 

varicose  veins  and  ulcers,  345.    See 
also  Tibia  and  Fibula,  335. 
Leg  splints,  431. 
Leontiasis  ossea,  50. 
Limited  motion  joints,  430. 
Limited  motion  splints,  429. 
Lipoma  arborescens,  333. 
Literature,  479. 
Lobster-claw  deformity  of  foot,  393. 

of  hand,  227. 
Locomotor  ataxia,  70. 
Lordosis,  132. 

Lorenz's  technic  for  reducing  con- 
genital dislocation  of  the  hip, 
255. 

after  treatment,  257. 


496 


INDEX 


Lovett's  stretching  board  for  scoliosis, 

160. 
Lower  extremity,  245. 

function  of,  245. 

structure  of,  245. 

MacCormac's   osteotomy  for   knock- 
knee,  317. 
Macewen's  osteotomj^  for  knock-knee, 

318. 
Macrosomia.     See  Gigantism,  9. 
Main    en    griffe.      See     Claw-Hand, 

230. 
Malignant  disease  of  bone,  59. 

carcinoma,  61. 

hypernephroma,  60. 

myeloma,  61. 

sarcoma,  59. 
Mallet  finger,  234. 
Manipulation,  96. 

of  club-foot,  363. 

of  flat-foot,  379. 

of  hip,  288. 

of  knee,  329. 
Manual  osteoclasis,  338. 
Manus  valga,  227, 
Manus  vara,  227. 
Marasmus,  12. 
Massage,  96. 
McCurdy's  drainage  in  osteomyelitis, 

32. 
McCurdy's  pedoclast,  364. 
McKenzie's  pedoclast,  364. 
Mechanical  treatment,  92.     See  also 

Section  on  Technic,  401. 
Metatarsalgia,  390. 
Microsomia.     See  Nanism,  8. 
Morton's  toe,  390. 
Mosetig-Moorhof 's  bone  wax  for  bone 

cavities,  32. 
Motion,  402. 
Multiple  myeloma,  61. 
Myositis  ossificans,  54. 
Myxedema,  10. 

Nanism,  8. 

Natural  cure  of  club-foot,  357. 


Natural  cure  of  coxitis,  294. 

of  Pott's  disease,  102. 
Neck  deformities,  101. 
Neck  splints : 

Bratz  splint,  104. 

Calot  jacket,  192,  468. 

forehead  strap,  473. 

Jury-mast,  467. 

plaster-of-Paris  collar,  474. 

Taylor  head  support,  472. 

wire  splint,  475. 
Nervous  affections,  63. 
Neurotic  spine,  203. 
Nichols's  treatment  of  osteomyelitis, 

.32. 
Normal  jiosture.     See  Posture. 
Normal  shoes,  351. 
Normal  sole  prints,  353. 

Obstetric  palsy,  212. 
Operation,  Albee's,  for  arthrodesis  of 
hip,  299. 
Burrell's,  for  recurrent  dislocation 

of  the  shoulder,  215. 
Gant's,  for  deforrnity  at  the  hip, 

288. 
Gibney's,   for   inversion   of   thigh, 

269. 
Goldthwait's,   for  bowed  scapula, 
208. 
for  slipping  patella,  312. 
Hoffa's,  for  congenital  dislocation 
of  the  hip,  254. 
for  hyperpronation  of  the  fore- 
arm, 225. 
Jones's,  for  calcaneo-valgus,  384. 
for  palsy  of  elbow,  225. 
for  relapsing  flat-foot,  379. 
for  spastic   adduction   of   thigh, 
269. 
MacCormac's,  for  knock-knee,  317. 
Macewen's,  for  knock-knee,  318. 
Phelps's,  for  club-foot,  363. 
Sherman's,  for  claw-foot,  389. 
Whitman's     for     calcaneo-valgus, 
384. 


INDEX 


497 


Operative  treatment,  93. 
Orthopedic,  etymology  of,  3. 
Orthopedic    practice,    diagnosis     in, 
71. 

examination  in,  71. 

history  taking  in,  75. 

laboratory  aids  in,  77. 

prevention  in,  79. 

prognosis  in,  81. 

records  in,  76. 

treatment  in,  85. 
of  complications,  85. 
of  deformity,  91. 
of  underlying  cause,  82. 
Orthopedic  shoes,  352. 
Orthopedic  surgery,  definition  of,  3. 

history  of,  3. 

scope  of,  401. 
Osgood's  apparatus  for  exercising  the 

foot,  374. 
Osteoarthritis,  45. 

of  hip,  297. 

of  knee,  331. 

of  spine,  200. 
Osteoarthropathie    hypertrophiante 

pneumonique,  48. 
Osteochondritis  syphilitica,  21. 
Osteochondroma,  53,  343. 
Osteoclasis,  339. 

instrumental,  339. 

manual,  339. 
Osteoclast,  Grattan's,  339. 
Osteodystrophia  fetalis,  12. 
Osteogenesis  imperfecta.     See  Osteo- 
dystrophia Fetalis, 
Osteoma,  54. 
Osteomalacia,  52. 
Osteomyelitis,  acute,  28. 

chronic,  33. 

subacute,  30. 
of  femur,  305. 
of  tibia,  343. 
Osteoperiostitis,  toxic,  48. 
Osteoperiostitis  syphilitica,  23. 
Osteophytes  of  os  calcis,  387. 
Osteotome,  Vance's,  368. 


Osteotomy,  Gant's,  for  hip  deformity, 
288. 

MacCormac's,  for  knock-knee,  317. 

Macewon's,  for  knock-knee.  318. 
Ostitis,  secondary  hyperplastic,  48. 
Ostitis  deformans,  50,  342. 
Ostitis  fibrosa,  51. 
Out-knee.     See  Bow-legs,  337. 

Paci's    manipulation    for     replacing 
congenital  dislocation   of   the 
hip,  254. 
Paget's  disease  of  the  bones,  50,  342. 
Palsies,  cerebral,  65. 

peripheral,  65. 
Erb's,  212. 

spinal,  65. 
Parasitic  bone  disease,  59. 
Patella,  311. 

ankylosis  of,  312. 

congenital,  absence  of,  308. 

fracture  of,  311. 

rupture  of  ligaments  of,  311. 

slipping,  311. 

tuberculosis  of,  312. 
Patellar  ligaments,  rupture  of,  311. 
Pectus  carinatum,  112. 
Pedoclast,  McCurdy's,  364. 

McKenzie's,  364. 

Schapps's,  364. 

Thomas's,  363. 
Pelvic  rest.     See  Hip  Rest,  447. 
Pelvic  splints,  457. 
Pelvis,  230. 

affections    of    sacro-iliac  joint   of, 
230. 

diseases  of,  230. 
Perinephritic  abscess,  188. 
Periosteal    dysplasia.         See    Osteo- 
dystrophia Fetalis,  12. 
Peripheral  palsies,  64. 
Pes  calcaneus.    See  Calcaneus,  381. 
Phalangitis  syphilitica,  24. 
Phalangitis  tuberculosa,  38. 
Phelps's  hip  splint,  2S5. 
Phelps's  operation  for  club-foot,  363, 


498 


INDEX 


Phocomelia.    See  Micromelia,  8. 

of  femur,  303. 

of  humerus,  222. 
Piano  practice,  142. 
Pied  en  griffe.     See  Claw-foot,  389. 
Pigeon  breast,  112. 
Pigeon  toes,  365. 

Plantaris  tendon,  rupture  of,  344. 
Plaster  cutter.  Stille's,  414. 
Plaster-of-Paris  bandages,  409. 

casts,  415. 

corset,  161,  469. 

jacket,  190,  463. 

Calot,  191,  192,  467. 

spica,  446. 

splints,  409. 
Pockets,  ichor,  39,  85. 
Poliomyelitis,  66. 
Polydactylism,  233,  392. 
Postural  deformities,  spinal,  119. 
lordosis,  132. 
round  back,  119. 
scoliosis,  135. 

weak  foot,  371. 
Posture,  96. 

normal  foot,  354. 

normal  sitting,  114,  139. 

normal  spinal,  113. 

normal  standing,  116. 

normal  walking,  115. 
Postures,  corrective,  for  round  back, 
125. 
for  scoliosis,  165. 
for  weak  feet,  374. 
Pott,  Percival,  4. 

Pott's    disease    of    the    spine.     See 
Spondylitis  Tuberculosa,  174. 
Pott's  fracture,  371. 
Pott's  paraplegia,  69,  184. 
Pressure,  402. 

Prevention  of  crippling  affections,  79. 
Professional  cramps,  237. 
Prognosis  in  crippling  affections,  81. 
Progressive  ankylosis  of  spine,  200. 
Purpura,  18. 
Purulent  and  other  infections,  27. 


Quiet  bone  abscess,  305. 

Rachischisis,  119. 

Rachitic    anterior    tibial    curvatuie, 

340. 
Rachitic  bow-legs,  337. 
Rachitic  coxa  vara,  263. 
Rachitic  deformities,  14. 

of  chest,  111. 

of  neck,  105. 
Rachitic  knock-knee,  313. 
Rachitic  recurvature  of  knee,  341. 
Rachitic  scohosis,  138. 
Rachitic  spine,  198. 
Rachitis.     See  Rickets,  13. 
Radius,  absence  of,  226. 
Recurrent  dislocation  of  patella,  311. 

of  shoulder,  214. 
Redundant  fingers,  233. 
Redundant  toes,  392. 
Retarded   growth   from   spondylitis, 

195. 
Retarded    growth    of    limb,     during 

coxitis,  201. 
Ribs,  beading  of,  14. 

cervical,  108. 

defect  of,  110. 
Rickets,  13. 

"acute,"  17. 

"adolescent,"  16. 

"senile,"  17. 
Rider's  bone,  54. 

Ridlon's    method    of    reducing    con- 
genital dislocation  of  the  hip, 
258. 
''Rheumatoid"  affections,  44. 
Roentgen,  4. 

Roentgen's  rays.    See  Skiagraphy,  78. 
Rosary,  rachitic,  14. 
Round  back,  119. 

causation  of,  120. 

diagnosis  of,  124. 

treatment  of,  124. 
gymnastic,  124. 
hygienic,  124. 
Round  shoulders,  119,  209. 


INDEX 


499 


Rupture  of  extensor  tendon  of  finger, 
234. 
of  liganientum  patellae,  311. 
of  plantaris  tendon,  344. 
of  quadriceps  tendon,  311. 
Ryerson's  modification  of  Sherman's 
operation  for  claw-foot,  389. 

Saber-leg,  341. 

Sacro-iliac    affections,    diagnosis    of, 
243. 

symj)tonis  of,  242. 

treatment  of,  244. 
Sacro-iliac  joints,  239. 

anatomy  of,  239. 

infections  of,  241. 

looseness  of,  239. 

osteoarthritis  of,  241. 

strains  of,  240. 
Sacrum,  congenital  anomalies  of,  118. 
Sanderson's  extension  apparatus,  448. 
Sarcoma  of  femur,  305. 

of  long  bones,  59. 

of  tibia,  343. 
Sayre,  Louis  A.,  4. 
Scapula,  207. 

bowed,  207. 

Goldthwait's  operation  for,  208. 

congenital  elevation  of,  208. 

exostoses  of,  211. 

osteomyelitis  of,  211. 

prominent,  210. 

variations  of,  207. 

winged,  211. 
Schanz's    method    of    reducing    con- 
genital hip  dislocation,  258. 
Schapp's  lever  for  club-foot,  364. 
Schede's  traction  method  of  reducing 
congenital   dislocation  of   the 
hip,  254. 
School  chair,  139 
School  desk,  138. 

correct  posture  at,  141. 
Schultze's  hip  rest,  414. 
Scoliosis,  135. 

acquired,  162. 


Scoliosis,  acf|uired,  contraction,  162. 
habit,  137. 
l)aralytic,  164. 
pathological,  164. 
postural,  137. 

classification  of,  147. 
diagnosis  of,  144,  154. 
examination  of,  145. 
pathological  anatomy  of,  142. 
prognosis  of,  155. 
record  of,  147. 
symjitoms  of,  152. 
treatment  of,  156. 
gymnastic,  165. 
hygienic,  156. 
mechanical,  157. 
postural,  156. 
static,  162. 
congenital,  136. 
Scurvy,  (scorbutus),  infantile,  17. 
Sebring's   (Emma  G.),  school  chair, 

139. 
Semilunar  cartilage,  displacement  of, 

334. 
Shaffer's     non-deforming     club-foot, 

367. 
Shaffer's  splint  for  internal  derange- 
ment of  knee,  334. 
Sherman's    operation   for    claw-foot, 

389. 
Shoe,  built  up  inner  edge,  374. 
natural  shape,  351. 
orthopedic,  352. 
Shoulder,  bursitis  of,  219. 
dangle,  213. 
injuries  to,  214. 
recurrent  dislocation  of,  214. 
Shoulder  joint,  ankylosis  of,  211,  221. 
infections  of,  221. 
trophic  changes  in,  221. 
Sitting  posture,  114. 

normal,  139. 
Skiagraphy,  78. 
Slip  joint,  430. 
Slipping  patella,  311. 
Snap  joint,  430. 


500 


INDEX 


Sole  prints,  353,  372. 
flat-foot,  373. 
normal,  3.53. 
Special  part,  100. 
Spica,  long,  452. 

short,  453. 
Spina  bifida,  119. 
.causing  paralytic  congenital  club- 
foot, 365. 
Spinal  corsets,  161,  469. 
Spinal  deformities,  113. 
antero-posterior,  119. 
lateral,  135. 
Spinal  diseases,  174. 
Spinal  frames  (Whitman),  189,  460. 
Spinal  jackets,  191,  463. 
Spinal  palsies,  65. 

Spinal  steel  splints  (Taylor),  193,  470. 
Spine,  actinomycotic,  200. 
ankylotic,  200. 
neurotic,  203. 
osteoarthritic,  200. 
osteomyelitic,  200. 
rachitic,  198. 
scoliotic,  156. 
syphilitic,  200. 
tabetic,  134. 
tuberculous,  174. 
typhoid,  200. 
Splint  joints,  430. 
Splinting,  general,  422. 
material  for,  409. 
celluloid,  419. 
leather,  419. 
plaster,  409. 
steel,  420. 
measurements  for,  421. 
mechanical  principles  of,  405. 
base,  406. 
grasp,  406. 
length,  408. 
pressure,  409. 
stiffness,  406. 
special,  431. 

ankle  and  tarsus,  360,  370,  432. 
arm  splints,  229,  457. 


Splinting,    special,    clavicle    splints, 
206. 
hip  splints,  285,  446. 
knee  splints,  315,  326,  437. 
neck  splints,  103,  472. 
pelvic  splints,  244,  457. 
spinal  splints,  189,  460. 
Splints,  adjustable,  423. 
bivalve,  413. 
fixation,  celluloid,  419. 
leather,  419. 
plaster,  409. 
steel,  420. 
jointed,  430,  445. 
limited  motion,  429. 
suspension,  424. 
traction,  426. 
Split-foot,  393. 
Split-hand,  227. 

Spondylarthritis  tuberculosa,  197. 
Spondylitis  traumatica,  199. 
SpondyUtis  tuberculosa,  174. 
complications  of,  181. 
paraplegia,  184. 
pockets  (abscess),  181. 
psoas  contraction,  183. 
differential  diagnosis  of,  185. 
occurrence  of,  174. 
pathology  of,  175. 
prognosis  of,  195. 
records  in,  179. 
symptoms  of,  177. 
treatment  of,  188. 
mechanical,  189. 
rest,  188. 
tonic,  188. 

plaster-of-Paris  jacket,  190. 
Calot  jacket,  191. 
with  jury-mast,  190. 
Taylor  splint,  193. 

with  head  support,  193. 
Whitman  frame,  189. 
Spondylolisthesis,  134. 
Spontaneous  fracture,  61. 
Sprain  of  ankle,  345. 
Sprengel's  deformity  of  scapula,  208. 


INDEX 


501 


Standing  posture,  115. 
Starr   and   Gallic   plaster  jacket   in- 
cluding head,  468. 
Steel  fixation  splints,  420. 

finishing,  422. 

fitting,  422. 

measurements  for,  421. 
Steel  wire  fixation  splints,  423. 
Stern,  droi)-phalaugettc,  234. 
Sternomastoid  torticollis,  101. 
Sternum,  fissures  and  defects  of,  110. 

funnel  chest  deformity  of,  110. 

pectus  carinatum  deformity  of.  111. 
Stille's  plaster  cutter,  414. 
Still's  disease,  47. 
Stopped  joints,  430. 
Straight-foot    walking  posture,    115, 

354. 
Strapping,  403. 

flat-foot,  376. 

sprain  of  ankle,  346. 

ulcers  of  leg,  345. 
Strohmeyer,  4. 
Subcutaneous  osteotomy,  315. 

tenotomy,  4,  94,  368. 
Supernumerary  fingers,  233. 
Supernumerary  toes,  392. 
Suspension,  425. 
Syndactylism,  233. 
Synovitis  of  the  knee,  320. 

acute,  320. 

chronic  tuberculous,  322,  325. 
Syphilis,  20. 

Talalgia,  387. 

Talipes  cavus.     See  Cavus,  386. 

Talipes  equino-varus.      See  Equino- 

varus,  355. 
Talipes  equinus.     See  Equinus,  366. 
Talipes  valgus.     See  Valgus,  371. 
Talipes  varus.     See  Varus,  355. 
Tarsus  deformities   (see  also  Foot), 
389. 

chilblains,  391. 

claw-foot,  391. 

corns  and  calluses,  388. 


Tarsus  deformities,  hump-foot,  388. 
injuries,  388. 
tenosynovitis,  388. 
tuberculosis  of,  349. 
weakness  of  anterior  arch,  390. 
Taylor,  C.  Fayette,  4. 

circular  chin  support,  472. 
clavicle  splint,  206. 
club-foot  splint,  362,  435. 
hip  splint,  285. 

lateral  suspension  apparatus,  150. 
spinal  splint,  198,  473. 
Technic,  401. 
Tenoplasty,  94. 
Tenosynovitis  of  foot,  388. 
Tenotomes,  368. 
Thomas  collar,  475. 
halter.  459. 
heel,  374. 
hip  splint,  326. 
knee  splint,  439. 
knock-knee  splint,  315,  442. 
wrench,  363. 
Thoracic  deformities,  110. 
Tibia  (and  fibula),  335. 
anterior  curvature  of,  340. 
bow-legs   and  genu  varum,  defor- 
mities of,  337. 
congenital  defects  of,  335. 
osteomyelitis  of,  343. 
ostitis  deformans  of,  342. 
recurvature  of,  341. 
saber-leg  deformity  of,  342. 
syphilis  of,  342. 
tumors  and  cysts  of,  343. 
Toe  deformities,  acquired,  392. 
hallux  rigidus,  395. 
hallux  valgus,  395. 
hallux  varus,  393. 
hammer-toe,  396. 
ingrown  toe-nail,  396. 
trigger-toe,  396. 
congenital,  397. 
absence,  392. 
deviation,  393. 
fusion,  392. 


502 


INDEX 


Toe   deformities,    congenital,    gigan- 
tism, 392. 
redundancy,  392. 
splitting,  393. 
Torticollis,  101. 
acquired,  101. 
acute,  106. 
atonic,  105. 
birth,  101. 
infections,  106. 
rachitic,  105. 
"rheumatic,"  106. 
spasmodic,  108. 
spastic,  108. 
spondylitic,  107. 
sternomastoid,  101. 
Bratz  apparatus  for,  104. 
congenital,  101. 
Toxic  osteoperiostitis,  48. 
Traction,  426. 

Echol's  appliance,  450. 
Sanderson's  appliance,  448. 
Treatment  of  complications,  85. 
abscess  (pockets),  85. 
ankylosis,  88. 
atrophy,  89. 
Treatment  of  deformity,  91. 
gymnastic,  95. 
mechanical,  92. 
operative,  93. 
Treatment  of  underlying  cause,  82. 
general  indications,  82. 
special  indications,  83. 
Trigger-toe,  397. 
Trophic  joints,  70. 
Tuberculosis,  34. 
diagnosis  of,  39. 
etiology  of,  37. 
pathological  anatomy  of,  35. 
prognosis  of,  41. 
symptoms  of,  39. 
treatment  of,  42. 
tuberculin  in  diagnosis  of,  40. 
eye  test,  41. 
inunction  method,  41. 
vaccination  test,  40. 


Tuberculosis    of    abdominal    glands, 
197. 

of  ankle,  347. 

of  elbow,  224. 

of  great  trochanter,  273,  274. 

of  hip.       See  Coxitis  Tuberculosa, 
269. 

of  knee,  322. 

of  shoulder,  221. 

ot  spine,  174. 

of  tarsus,  174. 

of  wrist,  349. 
Tumors  of  bone  and  cartilage,  53. 

ULna,  absence  of,  226. 
Unequal  growth  of  the  lower  Umbs, 
303. 

during  coxitis,  201. 

during  gonitis,  324. 
Untreated  club-foot,  357. 
Untreated  coxitis,  294. 
Untreated  Pott's  disease,  102. 
Ununited  fracture,  62. 

Valgus,  371. 

Vance's  osteotome,  368. 

Van  Winkle  corset-brace  for  scoliosis 

and  round  back,  158,  469. 
Varicose  ulcers,  345. 
Varicose  veins,  345. 
Varus,  355. 
Vertical  writing,  138. 
Villous  arthritis,  44,  332. 
Voice  culture,  142. 
Volkmann's  ischemic  palsy,  231. 

Walking  posture,  115,  354. 

Wandering  acetabulum,  272. 

Weak  ankle,  345,  371. 

Weak  back,  120. 

Weak  foot,  371. 

Weakness  of  anterior  arch  of  foot, 

390. 
White  swelling  of  the  knee.        See 

Gonitis  Tuberculosa,  322. 


INDEX 


503 


Whitman's  calcaneus  splint,  433. 
cast  for  flat-foot,  41G. 
frame  for  Pott's  disease,  180,  460. 
operation  for  calcaneo-valgus,  384. 
plate  for  flat-foot,  378,  418. 
posture     in     correction     of     knee 

flexion,  329. 
posture  in  fracture  of  the  femoral 

neck,  302. 


Wilson's  bracket,  465. 
Wrist,  227. 

disease  of,  232. 

ganglion  of,  232. 
Writing,  vertical,  138. 
Wryneck.     See  Torticollis,  101. 


X-rays.     See  Skiagraphy,  78. 


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